• Oct 2010
    AAO PPP Committee, Hoskins Center for Quality Eye Care
    Comprehensive Ophthalmology
    Compendium Type: I


    Preferred Practice Pattern guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American College of Physicians.3

    • All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.  
    • To rate individual studies, a scale based on SIGN1 is used. The definitions and levels of evidence to rate individual studies are as follows:


    High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias


    Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias


    Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias


    High quality systematic reviews of case control or cohort studies
    High quality case-control or cohort studies with a very low risk of confounding or bias and a moderate probability that the relationship is causal


    Well conducted case-control or cohort studies with a low risk of confounding or bias and a high probability that the relationship is causal


    Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal


    Non-analytic studies (e.g., case reports, case series)

    • Recommendations for care are formed based on the body of the evidence. The body of evidence quality ratings are defined by GRADE2 as follows:

    Good quality

    Further research is very unlikely to change our confidence in the estimate of effect

    Moderate quality

    Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

    Insufficient quality

    Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
    Any estimate of effect is very uncertain

    •  Key recommendations for care are defined by GRADE2 as follows: 

    Strong recommendation

    Used when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not

    Discretionary recommendation

    Used when the trade-offs are less certain-either because of low quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced

    • Key recommendations for care are listed in the Highlighted Recommendations for Care section and are repeated in the PPP in boxed text. A key recommendation may address an area of controversy for which there is insufficient evidence to make a recommendation.
    • Literature searches to update the PPP were undertaken in February and August 2010 and retrieved 1128 citations. Of these, 20 were used in the revision. Complete details of the literature search are available in the Literature Search Details section.


    Patients 65 or older without risk factors for eye disease should have comprehensive medical eye evaluations at the intervals shown in Table 1
    (Strong recommendation; moderate evidence)

    Patients under 65 without risk factors for eye disease should have comprehensive medical eye evaluations at the intervals shown in Table 1
    (Discretionary recommendation; insufficient evidence)

    TABLE 1. Comprehensive Medical Eye Evaluation for Adults With No Risk Factors (PDF 96k)

    Patients with diabetes mellitus should have comprehensive medical eye evaluations at the intervals shown in Table 2
    (Strong recommendation; moderate evidence)

    Patients with risk factors for glaucoma should have comprehensive medical eye evaluations at the intervals shown in Table 2
    (Strong recommendation; good evidence)

    TABLE 2. Comprehensive Medical Eye Evaluation for Patients With Diabetes Mellitus or Risk Factors for Glaucoma (PDF 157k)



    Adults without known ocular conditions or risk factors, or with previously identified conditions or risk factors, or with recurrent or new symptoms.


    • Detect and diagnose ocular abnormalities and diseases
    • Identify risk factors for ocular disease
    • Identify risk factors for systemic disease based on ocular findings
    • Establish the presence or absence of ocular signs or symptoms of systemic disease
    • Determine the refractive and health status of the eye, visual system, and related structures
    • Discuss the results and implications of the examination with the patient
    • Initiate an appropriate management plan (e.g., determine the frequency of future visits, further diagnostic tests, referral, or treatment as indicated)


    While various levels of medical eye evaluations have been proposed,4 comprehensive adult medical eye evaluation is the focus of this document. Patients may seek this service for a variety of reasons. A comprehensive medical eye evaluation is recommended for patients who have not been examined for a significant period of time by an ophthalmologist or who are being seen for the first time. Recommended intervals between comprehensive examinations vary with age and risk factors. A thorough ophthalmologic evaluation can detect common abnormalities of the visual system and related structures, as well as less common but extremely serious ones, such as ocular tumors. Such an evaluation can also uncover evidence of many forms of systemic disease with ophthalmic manifestations. All patients, particularly those with risk factors for ocular disease, are re-examined periodically to prevent or minimize visual loss by detecting and treating disease in its early stages. Patients in whom ocular diseases are identified require periodic comprehensive examinations for optimal monitoring and treatment of their conditions. With appropriate and timely intervention, potentially blinding diseases such as glaucoma, cataract, and diabetic retinopathy often have a favorable outcome. Studies have indicated that up to 40% of legal blindness found among nursing home residents,5 in both urban6 and rural7 communities, could have been prevented or ameliorated by appropriate ophthalmologic care. In a population-based study, 63% of the participants who had eye disease were not aware of it.8


    The rationale for performing periodic comprehensive medical eye examinations in adults without known ocular conditions or risk factors is to detect ocular diseases, visual dysfunction, or ophthalmic signs of systemic disease in the adult population. Early recognition, counseling, or treatment may preserve visual function or, in the case of systemic diseases, could prevent serious illness or premature death. Comprehensive medical eye evaluations are also performed periodically to evaluate new symptoms and monitor patients with previously identified eye conditions or risk factors.

    The public health impact of eye disease is substantial, because vision affects daily functioning.9-13 Improvement in visual function that occurs as a result of treatment of ocular disorders is accompanied by improvement in life satisfaction, mental health, and home and community activities.14-17 Vision plays an important role in mobility and in preventing falls.18-21 Untreated poor vision has been associated with cognitive decline, especially Alzheimer disease.22 In women 65 and older, poorer visual acuity and contrast sensitivity have been associated with a higher risk of mortality.23 Cataract surgery in older drivers has been shown to reduce the subsequent motor vehicle accident rate.24 Visual impairment, age-related macular degeneration (AMD), and cataract have been associated with an increased risk of mortality.25,26


    In 2000, about 937,000 adults 40 and older in the United States were legally blind (best corrected vision of 20/200 or less in each eye), and an additional 2.4 million were visually impaired despite best refractive correction.27 The highest frequencies of visual impairment and legal blindness were found in individuals 80 and older.27 Rates of visual impairment and legal blindness were disproportionately higher among individuals of African descent compared with individuals of European descent.27-29 Rates of low vision (defined as visual acuity less than 20/40 in the better-seeing eye) were higher among individuals of Hispanic/Latino descent compared with individuals of European or African descent.27,30

    Many patients will be unaware that they have a vision-threatening ocular condition because of the lack of early symptoms (see Table 3). These include common and often treatable conditions such as glaucoma, diabetic retinopathy, and macular degeneration.

    TABLE 3. Prevalence of Major Ocular Diseases and Conditions that May Be Asymptomatic (PDF 110k)

    Open-Angle Glaucoma
    In the United States, the overall prevalence of open-angle glaucoma for adults 40 and older is estimated to be 1.9%.31 Open-angle glaucoma affects an estimated 2.22 million people in the United States, and by 2020 that number will increase by 50% due to the aging of the population.31 Based on data extrapolated from the Baltimore Eye Survey, about half of those with glaucoma were unaware that they had the disease at the time the study diagnosis was made.32,33 Glaucoma of all types is one of the leading causes of legal blindness in the United States.6,27 The prevalence of primary open-angle glaucoma (POAG) is higher in individuals of West African, Afro-Caribbean, Hispanic, or Latino origin than in other groups.31,32,34-36 Blindness from glaucoma is at least six times more prevalent in African Americans than in Caucasian Americans.6Early detection and treatment of POAG may prevent or delay loss of vision, but, unfortunately, it is often asymptomatic until irreversible visual loss is extensive.37,38

    Primary Angle Closure
    There are considerable differences in the prevalence of angle closure among racial and ethnic groups. The highest rates are reported in Inuit,39-41 Chinese,42-46 and other Asian47-55 populations; lower rates are reported in populations of African and African-derived origin56-58 and European and European-derived origin.35,59-64 Primary angle-closure glaucoma may account for the majority of glaucoma in Asian populations.47,65,66

    Diabetes Mellitus
    An estimated 9% of the U.S. population 20 or older (19 million persons) have diabetes mellitus (both diagnosed and undiagnosed); about one-third are not aware that they have the disease.67 An additional 26% of adults (54 million persons) have impaired fasting blood glucose levels.67 The prevalence rate for retinopathy for all adults 40 and older in the United States is 3.4% (4.1 million persons); the prevalence rate for vision-threatening retinopathy is 0.7% (899,000 persons).68 Assuming a similar prevalence of diabetes mellitus, the projected numbers in 2020 would be 6 million persons with diabetic retinopathy and 1.34 million persons with vision-threatening diabetic retinopathy. Although effective treatment for reducing the risk of blinding diabetic retinopathy is available,69,70 the number of patients with diabetes referred by their primary care physicians or who present for ophthalmic care is far below the guidelines of the American Diabetic Association and the American Academy of Ophthalmology.71-75 Regular examination and follow-up of all patients with diabetes reinforces the importance of recommended dietary and medication compliance, and can lead to earlier detection and treatment of retinopathy. Regular examinations, coupled with appropriate medical and laser treatment for those who require it, have been shown to be extremely cost-effective in the diabetic population, particularly when compared with disability payments for those who would otherwise become blind.76-78

    Age-Related Macular Degeneration
    Age-related macular degeneration is a leading cause of severe, irreversible vision impairment among Caucasian Americans.112 In the United States, an estimated 1.75 million individuals 40 and older have AMD, and this number is estimated to increase to 2.95 million by the year 2020.112 The prevalence, incidence, and progression of AMD and most associated features (e.g., large drusen) increase significantly with age.105,106,112 The prevalence of AMD in white females 60 to 64 is 0.3%; the rate increases to 16.4% in white females 80 and older.112 Age-related macular degeneration is usually asymptomatic in its early stages, although it is possible to identify patients who have an increased risk of developing choroidal neovascularization or advanced AMD.110 Identifying those patients at higher risk may result in a greater percentage receiving high-dose nutritional supplements of antioxidants and zinc, which have been shown to have preventative efficacy.113 Of the 1.3 million people considered to be at high risk for progression to advanced AMD for whom the high-dose nutritional supplement of antioxidants and zinc is recommended, more than 300,000 could delay disease progression with associated vision loss if they were identified and treated.113

    Cigarette smoking has been consistently identified in numerous studies as a risk factor for developing AMD, which increases with the number of pack-years smoked.114-121 Therefore, informing patients who smoke about this risk may influence them to stop smoking, thus reducing the incidence of AMD. Patients with neovascular AMD report a substantial decline in quality of life and increased need for assistance with activities of daily living, which progressed as visual acuity worsened.122 Early treatment of AMD carries a more favorable prognosis. Because the early symptoms may be subtle, however, a comprehensive eye examination may represent a patient's best opportunity to be diagnosed and treated at an earlier and potentially more favorable stage, before the development of severe visual loss.

    Cataract remains a significant cause of visual disability in the United States, accounting for approximately 50% of low-vision cases in adults over 40.27 Cataract is the leading cause of treatable blindness among Americans of African descent 40 and older, and the leading cause of low vision among individuals of African, Hispanic/Latino, and European descent.27 Because smoking increases the risk of cataract progression,123,124 informing smokers about this and other associated ocular and systemic diseases may influence them to stop smoking.

    Other Ocular Disorders
    Other examples of high-risk conditions or diseases for which medical eye examinations are indicated include a past history of ocular trauma or the presence of abnormalities of the anterior segment that increase the risk of open-angle and angle-closure glaucoma. High degrees of myopia and abnormalities of the posterior segment such as retinal tears and degenerations increase the risk of retinal detachment.


    Important systemic effects of infectious, neoplastic, autoimmune, and vascular diseases may be revealed during the ocular examination. Therefore, the initial diagnosis of a number of systemic diseases may be made during a comprehensive ophthalmologic evaluation.

    The following components of the comprehensive examination may identify examples of systemic diseases:

    • External examination: orbital tumor, thyroid eye disease, metabolic storage diseases
    • Pupillary function: optic nerve disorders (e.g., optic nerve glioma)
    • Ocular alignment and motility: neurological disorders (e.g., myasthenia gravis, thyroid eye disease, central nervous system defects or aneurysm, multiple sclerosis)
    • Visual fields by confrontation: chiasmal tumors
    • Anterior segment: drug or heavy metal toxicity, sarcoidosis, immune-mediated diseases, metabolic, endocrine, or storage diseases
    • Lens: Alport syndrome, Apert syndrome, atopic disease, juvenile rheumatoid arthritis, myotonic dystrophy, Wilson disease, homocystinuria
    • Posterior segment: systemic hypertension, diabetes mellitus, infectious diseases (e.g., acquired immunodeficiency syndrome, tuberculosis, syphilis, histoplasmosis, toxoplasmosis), immune-mediated diseases, vasculitis, primary or metastatic tumors, metabolic storage diseases and other phakomatoses, hematologic diseases, cerebrovascular disease, increased intracranial pressure, toxicity from hydroxychloroquine, tamoxifen, or phenothiazines


    A comprehensive medical eye evaluation includes a history, examination, diagnosis, and initiation of management. Included within each part of the evaluation is a series of items particularly effective for the detection, diagnosis, and choice of appropriate therapy for refractive error, ocular disease, and systemic disease. The items listed are basic areas of evaluation or investigation and are not meant to exclude additional elements when appropriate. For example, because history taking is an interactive process, the patient's responses may guide the clinician to pursue additional questions and evaluation.


    In general, a thorough history may include the following items, although the exact composition varies with the patient's particular problems and needs.

    • Demographic data (e.g., name, date of birth, gender, and, where appropriate, ethnicity or race)
    • The identity of the patient's other pertinent health care providers
    • Chief complaint and history of present illness
    • Present status of visual function (e.g., patient's self-assessment of visual status, visual needs, any recent or current visual symptoms, and use of eyeglasses or contact lenses)
    • Ocular symptoms (e.g., eyelid swelling, diplopia, redness, photophobia)
    • Ocular history (e.g., prior eye diseases, injuries, surgery, including cosmetic eyelid and refractive surgery, or other treatments and medications)
    • Systemic history: pertinent medical conditions and previous surgery
    • Medications: ophthalmic and systemic medications currently used, including nutritional supplements
    • Allergies or adverse reactions to medications
    • Family history: pertinent familial ocular and systemic disease
    • Social history (e.g., occupation; tobacco, alcohol, recreational drug use; family and living situation as appropriate)
    • Directed review of systems


    The comprehensive eye examination consists of an evaluation of the physiological function and the anatomical status of the eye, visual system, and its related structures. This usually includes the following elements:

    • Visual acuity with current correction (the power of the present correction recorded) at distance and, when appropriate, at near
    • Measurement of best corrected visual acuity (with a refraction when indicated)
    • Visual fields by confrontation
    • External examination (e.g., eyelid position and character, lashes, lacrimal apparatus and tear function; globe position; and pertinent facial features)
    • Pupillary function (e.g., size and response to light, relative afferent pupillary defect)
    • Ocular alignment and motility
    • Slit-lamp biomicroscopic examination: eyelid margins and lashes; tear film; conjunctiva; sclera; cornea; anterior chamber; and assessment of central and peripheral anterior chamber depth, iris, lens, and anterior vitreous
    • Intraocular pressure measurement, preferably with a contact applanation method (typically a Goldmann tonometer); contact tonometry may be deferred in the setting of suspected ocular infection
    • Fundus examination: mid and posterior vitreous, retina (including posterior pole and periphery), vasculature, and optic nerve
    • Assessment of relevant aspects of patient's mental and physical status

    Examination of anterior segment structures routinely involves gross and biomicroscopic evaluation prior to and after dilation. Evaluation of structures situated posterior to the iris is best performed through a dilated pupil. Optimal examination of the peripheral retina requires the use of the indirect ophthalmoscope or slit-lamp fundus biomicroscopy. Optimal examination of the macula and optic nerve requires the use of the slit-lamp biomicroscope and accessory diagnostic lenses.

    Based on the patient's history and findings, additional tests or evaluations might be indicated to evaluate further a particular structure or function. These are not routinely part of the comprehensive medical eye clinical evaluation. Specialized clinical evaluation may include the following:        

    • Monocular near-vision testing
    • Potential acuity testing
    • Glare testing
    • Contrast sensitivity testing
    • Color-vision testing
    • Testing of stereoacuity and fusion
    • Testing of accommodation and convergence amplitudes
    • Central visual field testing (Amsler grid)
    • Pupillometry
    • Expanded evaluation of ocular motility and alignment in multiple fields of gaze at distance and near
    • Exophthalmometry (e.g., Hertel)
    • Tear breakup time
    • Schirmer testing and ocular surface dye staining
    • Corneal sensation
    • Gonioscopy
    • Functional evaluation of the nasolacrimal tear drainage system
    • Extended indirect ophthalmoscopy with scleral indentation
    • Contact lens stereoscopic biomicroscopy (e.g., Goldmann three-mirror lens)

    Additional diagnostic testing may include the following:

    • Analysis of the corneal shape (e.g., keratometry and/or corneal topography)
    • Ocular wavefront analysis (aberrometry)
    • Measurement of corneal thickness (pachymetry)
    • Corneal endothelial cell analysis
    • External, slit-lamp, or fundus photography
    • Anterior and posterior segment imaging (e.g., optical coherence tomography, Scheimpflug photography, high-frequency ultrasound, or confocal microscopy)
    • Visual fields by automated perimetry
    • Stereophotography or computer-based image analysis of the optic disc and retinal nerve fiber layer or macula
    • Ophthalmic ultrasonography
    • Fluorescein or indocyanine green angiography
    • Electrophysiological testing
    • Microbiology and cytology
    • In-office point-of-care testing (i.e., immunochromatography)
    • Radiologic testing
    • Laboratory tests for systemic disease


    The ophthalmologist evaluates and integrates the findings of the comprehensive ophthalmologic examination with all aspects of the patient's health status and social situation in determining an appropriate course of action. Patients are considered in one of three general categories based on the results of the evaluation: patients with no risk factors, patients with risk factors, and patients with conditions that require intervention.

    Category I: Patients with No Risk Factors
    When the initial comprehensive evaluation is normal or involves only optical abnormalities that require corrective lenses, the ophthalmologist reviews the findings with the patient and advises him/her of the appropriate interval for re-examination. Although this category of patients is considered low risk, periodic re-examination is indicated to detect new, potentially asymptomatic, or unrecognized ocular disease, the incidence of which increases with age, such as glaucoma, diabetic retinopathy, and AMD.

    A 5-year observationalstudy of a nationally representative cohort of Medicare beneficiaries showed that patients 65 and older who had more regular eye examinations experienced less decline in vision and functional status than those who had less frequent examinations.125 For each additional year in which a patient received an eye examination, there was an increased likelihood of continuing to read newsprint and maintaining activities of daily living, and a decreased risk of developing new limitations in activities of daily living and instrumental activities of daily living. Instrumental activities of daily living are activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.

    There is no strong evidence in the literature to define the optimal frequency of periodic eye examinations of patients under 65 with no eye symptoms or signs. There is some evidence that clinically significant fundus abnormalities in asymptomatic patients increase with age,126 but other evidence suggests that the diagnostic yield of dilated fundus examination in asymptomatic patients is not high, particularly in younger age groups.127 In the absence of symptoms or other indications following the initial comprehensive medical eye evaluation, periodic evaluations are recommended at the frequency indicated in Table 1, which takes into account the relationship between increasing age and the risk of asymptomatic or undiagnosed disease. At the time of each comprehensive medical eye evaluation, the ophthalmologist will reassess the patient to determine the appropriate follow-up interval. Adults with no signs or risk factors for eye disease should receive a comprehensive medical eye evaluation at age 40 if they have not previously received one.128

    Interim evaluations, such as screenings, refractions, or less extensive evaluations, are indicated to address episodic minor problems and complaints or for patient reassurance.Other situations may warrant a comprehensive medical eye evaluation. The extent of the interim evaluation to be performed is determined by the patient's condition and complaints and by the ophthalmologist's medical judgment.

    Patients 65 or older without risk factors for eye disease should have comprehensive medical eye evaluations at the intervals shown in Table 1
    (Strong recommendation; moderate evidence)

    Patients under 65 without risk factors for eye disease should have comprehensive medical eye evaluations at the intervals shown in Table 1
    (Discretionary recommendation; insufficient evidence)

    TABLE 1. Comprehensive Medical Eye Evaluation for Adults With No Risk Factors (PDF 96k)

    Category II: Patients with Risk Factors
    A patient is considered to be at increased risk when the evaluation reveals signs that are suggestive of a potentially abnormal condition or when risk factors for developing ocular disease are identified but the patient does not yet require intervention. These situations may merit closer follow-up to monitor the patient's ocular health and to detect early signs of disease.

    The ophthalmologist determines an appropriate follow-up interval for each patient based on the presence of early signs, risk factors, the incidence of disease, and the potential rate of progression of a given disease. For example, individuals of African descent might require more frequent examinations, because they are at higher risk for an earlier onset and more rapid progression of glaucoma due to the higher risk in this population. It is recommended that patients with the conditions and risk factors noted in Table 2 undergo a comprehensive medical eye evaluation at the listed intervals.

    Patients with diabetes mellitus should have comprehensive medical eye evaluations at the intervals shown in Table 2
    (Strong recommendation; moderate evidence)

    Patients with risk factors for glaucoma should have comprehensive medical eye evaluations at the intervals shown in Table 2
    (Strong recommendation; good evidence)

    TABLE 2. Comprehensive Medical Eye Evaluation for Patients With Diabetes Mellitus or Risk Factors for Glaucoma (PDF 157k)

    Category III: Conditions that Require Intervention
    For a patient with ophthalmic or refractive abnormalities, the ophthalmologist prescribes glasses, contact lenses, or other optical devices; treats with medications; arranges for additional evaluation, testing, and follow-up as appropriate; and performs nonsurgical or surgical procedures including laser surgery when indicated.

    The ophthalmologist should communicate the examination findings and the need for further evaluation, testing, treatment, or follow-up. Certain findings should be shared with the patient's primary care physician or other specialists, as appropriate. For a patient with systemic abnormalities, the ophthalmologist may advise further evaluation or referral, as appropriate.

    Vision rehabilitation restores functional ability,129 and patients with reduced visual function may be referred for vision rehabilitation and social services.130 More information on vision rehabilitation, including materials for patients, is available at www.aao.org/smartsight.


    Of all health care providers, the ophthalmologist best combines a thorough understanding of ocular pathology and disease processes; familiarity with systemic disorders with ocular manifestations; and clinical skills and experience in ocular diagnosis, treatment, and medical decision making. This makes the ophthalmologist the most qualified professional to perform and oversee a comprehensive medical eye evaluation. Frequently, and appropriately, some testing and data collection are conducted by trained personnel under the ophthalmologist's supervision.


    In 2006, the societal cost of major visual disorders (AMD, cataract, diabetic retinopathy, POAG, refractive errors) among U.S. residents 40 and older was estimated to be $35.4 billion. This total comprised $16.2 billion in direct medical costs, $11.1 billion in other direct costs, and $8 billion in productivity losses.131 These costs do not include associated comorbid conditions such as depression or injury.

    In another study, U.S. residents 40 and older with blindness or visual impairment had estimated excess medical expenditures of $5.1 billion.132 This estimate includes the cost of home care and informal care for blind and visually impaired adults. The study also estimated that the total number of quality adjusted life years lost for individuals with blindness or visual impairment was 209,000. Valuing each year lost at $50,000 would add $10.4 billion to this estimate of the annual economic impact of visual impairment and blindness.

    In Australia, researchers estimated that the economic impact and cost in 2004 was A$9.85 billion (≈ US$7.02 billion), with vision disorders ranking seventh in the direct health care costs of various health conditions.133 Vision loss was also the seventh leading cause of disability in Australia, with the years of life lost to disability valued at A$4.8 billion (≈ US$3.42 billion) annually.

    In 2006, the annual nonmedical costs related to visual impairment in four European countries (France, Germany, Italy, and the United Kingdom) were estimated at €10,749 million (≈ US$13,712 million) in France, €9,214 million (≈ US$11,754 million) in Germany, €12,069 million (≈ US$15,396 million) in Italy and €15,180 million (≈ US$19,364 million) in the United Kingdom.134


    Providing quality care
    is the physician's foremost ethical obligation, and is
    the basis of public trust in physicians.
    AMA Board of Trustees, 1986

    Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.

    The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest feasible level, consistent with the needs of patients, through training and continuing education. The ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or through referral to appropriate persons and facilities that will provide such care, and he or she supports activities that promote health and prevent disease and disability.

    The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The ophthalmologist respects the dignity and integrity of his or her patients, and does not exploit their vulnerability.

    Quality ophthalmic care has the following optimal attributes, among others.

    • The essence of quality care is a meaningful partnership relationship between patient and physician. The ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure their meaningful participation (appropriate to their unique physical, intellectual and emotional state) in decisions affecting their management and care, to improve their motivation and compliance with the agreed plan of treatment, and to help alleviate their fears and concerns.
    • The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the urgency and nature of the patient's condition and unique needs and desires.
    • The ophthalmologist carries out only those procedures for which he or she is adequately trained, experienced and competent, or, when necessary, is assisted by someone who is, depending on the urgency of the problem and availability and accessibility of alternative providers.
    • Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be described as follows.
      • The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own ability to provide such care.
      • The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative patient care.
      • When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and procedures for obtaining it.
      • The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications of the person to whom the referral is made, and access and availability.
      • The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other medical or surgical problem. Consultants are suggested for their skill, competence, and accessibility. They receive as complete and accurate an accounting of the problem as necessary to provide efficient and effective advice or intervention, and in turn respond in an adequate and timely manner.
      • The ophthalmologist maintains complete and accurate medical records.
      • On appropriate request, the ophthalmologist provides a full and accurate rendering of the patient's records in his or her possession.
      • The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective manner and takes appropriate actions.
      • The ophthalmologist and those who assist in providing care identify themselves and their profession
      • For patients whose conditions fail to respond to treatment and for whom further treatment is unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and social services, and referral as appropriate and accessible.
    • Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately conversant with the patient's condition by collecting pertinent historical information and performing relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks, benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks and benefits of no treatment.
    • The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its demonstrated safety and efficacy.
    • The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and assessing his or her personal performance in relation to established standards, and by revising or altering his or her practices and techniques appropriately.
    • The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate professional channels, knowledge gained through clinical research and practice. This includes alerting colleagues of instances of unusual or unexpected rates of complications and problems related to new drugs, devices or procedures.
    • The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with potential ocular and systemic complications requiring immediate attention.
    • The ophthalmologist also provides ophthalmic care in a manner that is cost effective without unacceptably compromising accepted standards of quality.

    Reviewed by: Council
    Approved by: Board of Trustees
    October 12, 1988

    2nd Printing: January 1991
    3rd Printing: August 2001
    4th Printing: July 2005


    Basic and Clinical Science Course
         Fundamentals and Principles of Ophthalmology (Section 2, 2010-2011)

    Clinical Education - Residents
         Practical Ophthalmology: A Manual for Beginning Residents, 6th ed. (2009)

    To order any of these materials, please call the Academy's Customer Service number, 866.561.8558 (U.S. only) or 415.561.8540 or visit www.aao.org/store.


    1. Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer's handbook. Available at: www.sign.ac.uk/methodology/index.html. Accessed September 23, 2010
    2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
    3. GRADE Working Group. Organizations that have endorsed or that are using GRADE. Available at: www.gradeworkinggroup.org/society/index.htm. Accessed August 27, 2010.
    4. American Academy of Ophthalmology. Core Eye Care Benefits Package. San Francisco, CA: American Academy of Ophthalmology, 1993.
    5. Tielsch JM, Javitt JC, Coleman A, et al. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. N Engl J Med 1995;332:1205-9.
    6. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991;325:1412-7.
    7. Dana MR, Tielsch JM, Enger C, et al. Visual impairment in a rural Appalachian community. Prevalence and causes. JAMA 1990;264:2400-5.
    8. Varma R, Mohanty SA, Deneen J, et al, Los Angeles Latino Eye Study Group. Burden and predictors of undetected eye disease in Mexican-Americans: the Los Angeles Latino Eye Study. Med Care 2008;46:497-506.
    9. Chia EM, Mitchell P, Ojaimi E, et al. Assessment of vision-related quality of life in an older population subsample: The Blue Mountains Eye Study. Ophthalmic Epidemiol 2006;13:371-7.
    10. Jacobs JM, Hammerman-Rozenberg R, Maaravi Y, et al. The impact of visual impairment on health, function and mortality. Aging Clin Exp Res 2005;17:281-6.
    11. Lamoureux EL, Fenwick E, Moore K, et al. Impact of the severity of distance and near-vision impairment on depression and vision-specific quality of life in older people living in residential care. Invest Ophthalmol Vis Sci 2009;50:4103-9.
    12. Patino CM, McKean-Cowdin R, Azen SP, et al. Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology 2010;117:199-206 e1.
    13. McKean-Cowdin R, Varma R, Wu J, et al. Severity of visual field loss and health-related quality of life. Am J Ophthalmol 2007;143:1013-23.
    14. Coleman AL, Yu F, Keeler E, Mangione CM. Treatment of uncorrected refractive error improves vision-specific quality of life. J Am Geriatr Soc 2006;54:883-90.
    15. Datta S, Foss AJ, Grainge MJ, et al. The importance of acuity, stereopsis, and contrast sensitivity for health-related quality of life in elderly women with cataracts. Invest Ophthalmol Vis Sci 2008;49:1-6.
    16. Owsley C, McGwin G, Jr., Scilley K, et al. Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol 2007;125:1471-7.
    17. Owsley C, McGwin G, Jr., Scilley K, et al. Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol 2007;91:1359-63.
    18. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc 1998;46:58-64.
    19. Lord SR, Dayhew J. Visual risk factors for falls in older people. J Am Geriatr Soc 2001;49:508-15.
    20. Vu HT, Keeffe JE, McCarty CA, Taylor HR. Impact of unilateral and bilateral vision loss on quality of life. Br J Ophthalmol 2005;89:360-3.
    21. Coleman AL, Cummings SR, Yu F, et al. Binocular visual-field loss increases the risk of future falls in older white women. J Am Geriatr Soc 2007;55:357-64.
    22. Rogers MA, Langa KM. Untreated poor vision: a contributing factor to late-life dementia. Am J Epidemiol 2010;171:728-35.
    23. Pedula KL, Coleman AL, Hillier TA, et al. Visual acuity, contrast sensitivity, and mortality in older women: Study of osteoporotic fractures. J Am Geriatr Soc 2006;54:1871-7.
    24. Owsley C, McGwin G, Jr., Sloane M, et al. Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA 2002;288:841-9.
    25. Cugati S, Cumming RG, Smith W, et al. Visual impairment, age-related macular degeneration, cataract, and long-term mortality: the Blue Mountains Eye Study. Arch Ophthalmol 2007;125:917-24.
    26. Knudtson MD, Klein BE, Klein R. Age-related eye disease, visual impairment, and survival: the Beaver Dam Eye Study. Arch Ophthalmol 2006;124:243-9.
    27. Congdon N, O'Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122:477-85.
    28. Tielsch JM, Sommer A, Witt K, et al. Blindness and visual impairment in an American urban population. The Baltimore Eye Survey. Arch Ophthalmol 1990;108:286-90.
    29. Munoz B, West SK, Rubin GS, et al. Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study. Arch Ophthalmol 2000;118:819-25.
    30. Varma R, Chung J, Foong AW, et al. Four-year incidence and progression of visual impairment in Latinos: the Los Angeles Latino Eye Study. Am J Ophthalmol 2010;149:713-27.
    31. Friedman DS, Wolfs RC, O'Colmain BJ, et al. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol 2004;122:532-8.
    32. Tielsch JM, Sommer A, Katz J, et al. Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey. JAMA 1991;266:369-74.
    33. Quigley HA, Vitale S. Models of open-angle glaucoma prevalence and incidence in the United States. Invest Ophthalmol Vis Sci 1997;38:83-91.
    34. Leske MC, Connell AM, Schachat AP, Hyman L. The Barbados Eye Study. Prevalence of open angle glaucoma. Arch Ophthalmol 1994;112:821-9.
    35. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open-angle glaucoma in Australia. The Blue Mountains Eye Study. Ophthalmology 1996;103:1661-9.
    36. Varma R, Ying-Lai M, Francis BA, et al, Los Angeles Latino Eye Study Group. Prevalence of open-angle glaucoma and ocular hypertension in Latinos: the Los Angeles Latino Eye Study. Ophthalmology 2004;111:1439-48.
    37. Collaborative Normal-Tension Glaucoma Study Group. Comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. Am J Ophthalmol 1998;126:487-97.
    38. Van Veldhuisen PC, Ederer F, Gaasterland DE, et al, AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol 2000;130:429-40.
    39. Van Rens GH, Arkell SM, Charlton W, Doesburg W. Primary angle-closure glaucoma among Alaskan Eskimos. Doc Ophthalmol 1988;70:265-76.
    40. Arkell SM, Lightman DA, Sommer A, et al. The prevalence of glaucoma among Eskimos of northwest Alaska. Arch Ophthalmol 1987;105:482-5.
    41. Bourne RR, Sorensen KE, Klauber A, et al. Glaucoma in East Greenlandic Inuit--a population survey in Ittoqqortoormiit (Scoresbysund). Acta Ophthalmol Scand 2001;79:462-7.
    42. Congdon NG, Quigley HA, Hung PT, et al. Screening techniques for angle-closure glaucoma in rural Taiwan. Acta Ophthalmol Scand 1996;74:113-9.
    43. He M, Foster PJ, Ge J, et al. Prevalence and clinical characteristics of glaucoma in adult Chinese: a population-based study in Liwan District, Guangzhou. Invest Ophthalmol Vis Sci 2006;47:2782-8.
    44. Foster PJ, Baasanhu J, Alsbirk PH, et al. Glaucoma in Mongolia. A population-based survey in Hovsgol province, northern Mongolia. Arch Ophthalmol 1996;114:1235-41.
    45. Xu L, Zhang L, Xia CR, et al. The prevalence and its effective factors of primary angle-closure glaucoma in defined populations of rural and urban in Beijing [in Chinese]. Zhonghua Yan Ke Za Zhi 2005;41:8-14.
    46. Foster PJ, Oen FT, Machin D, et al. The prevalence of glaucoma in Chinese residents of Singapore: a cross-sectional population survey of the Tanjong Pagar district. Arch Ophthalmol 2000;118:1105-11.
    47. Casson RJ, Newland HS, Muecke J, et al. Prevalence of glaucoma in rural Myanmar: the Meiktila Eye Study. Br J Ophthalmol 2007;91:710-4.
    48. Salmon JF, Mermoud A, Ivey A, et al. The prevalence of primary angle closure glaucoma and open angle glaucoma in Mamre, western Cape, South Africa. Arch Ophthalmol 1993;111:1263-9.
    49. Dandona L, Dandona R, Mandal P, et al. Angle-closure glaucoma in an urban population in southern India. The Andhra Pradesh eye disease study. Ophthalmology 2000;107:1710-6.
    50. Bourne RR, Sukudom P, Foster PJ, et al. Prevalence of glaucoma in Thailand: a population based survey in Rom Klao District, Bangkok. Br J Ophthalmol 2003;87:1069-74.
    51. Vijaya L, George R, Arvind H, et al. Prevalence of angle-closure disease in a rural southern Indian population. Arch Ophthalmol 2006;124:403-9.
    52. Ramakrishnan R, Nirmalan PK, Krishnadas R, et al. Glaucoma in a rural population of southern India: the Aravind comprehensive eye survey. Ophthalmology 2003;110:1484-90.
    53. Rahman MM, Rahman N, Foster PJ, et al. The prevalence of glaucoma in Bangladesh: a population based survey in Dhaka division. Br J Ophthalmol 2004;88:1493-7.
    54. Shiose Y, Kitazawa Y, Tsukahara S, et al. Epidemiology of glaucoma in Japan--a nationwide glaucoma survey. Jpn J Ophthalmol 1991;35:133-55.
    55. Yamamoto T, Iwase A, Araie M, et al. The Tajimi Study report 2: prevalence of primary angle closure and secondary glaucoma in a Japanese population. Ophthalmology 2005;112:1661-9.
    56. Tielsch JM, Katz J, Singh K, et al. A population-based evaluation of glaucoma screening: the Baltimore Eye Survey. Am J Epidemiol 1991;134:1102-10.
    57. Buhrmann RR, Quigley HA, Barron Y, et al. Prevalence of glaucoma in a rural East African population. Invest Ophthalmol Vis Sci 2000;41:40-8.
    58. Rotchford AP, Kirwan JF, Muller MA, et al. Temba glaucoma study: a population-based cross-sectional survey in urban South Africa. Ophthalmology 2003;110:376-82.
    59. Bonomi L, Marchini G, Marraffa M, et al. Prevalence of glaucoma and intraocular pressure distribution in a defined population. The Egna-Neumarkt Study. Ophthalmology 1998;105:209-15.
    60. Coffey M, Reidy A, Wormald R, et al. Prevalence of glaucoma in the west of Ireland. Br J Ophthalmol 1993;77:17-21.
    61. Wensor MD, McCarty CA, Stanislavsky YL, et al. The prevalence of glaucoma in the Melbourne Visual Impairment Project. Ophthalmology 1998;105:733-9.
    62. Klein BE, Klein R, Sponsel WE, et al. Prevalence of glaucoma. The Beaver Dam Eye Study. Ophthalmology 1992;99:1499-504.
    63. Dielemans I, Vingerling JR, Wolfs RC, et al. The prevalence of primary open-angle glaucoma in a population-based study in The Netherlands. The Rotterdam Study. Ophthalmology 1994;101:1851-5.
    64. Bengtsson B. The prevalence of glaucoma. Br J Ophthalmol 1981;65:46-9.
    65. Congdon N, Wang F, Tielsch JM. Issues in the epidemiology and population-based screening of primary angle-closure glaucoma. Surv Ophthalmol 1992;36:411-23.
    66. Foster PJ, Johnson GJ. Glaucoma in China: how big is the problem? Br J Ophthalmol 2001;85:1277-82.
    67. Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999-2002. Diabetes Care 2006;29:1263-8.
    68. Kempen JH, O'Colmain BJ, Leske MC, et al. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol 2004;122:552-63.
    69. Indications for photocoagulation treatment of diabetic retinopathy: Diabetic Retinopathy Study Report no. 14. The Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin 1987;27:239-53.
    70. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1987;94:761-74.
    71. Schoenfeld ER, Greene JM, Wu SY, Leske MC. Patterns of adherence to diabetes vision care guidelines: baseline findings from the Diabetic Retinopathy Awareness Program. Ophthalmology 2001;108:563-71.
    72. Fong DS, Sharza M, Chen W, et al. Vision loss among diabetics in a group model Health Maintenance Organization (HMO). Am J Ophthalmol 2002;133:236-41.
    73. Lee PP, Feldman ZW, Ostermann J, et al. Longitudinal rates of annual eye examinations of persons with diabetes and chronic eye diseases. Ophthalmology 2003;110:1952-9.
    74. Sloan FA, Brown DS, Carlisle ES, et al. Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res 2004;39:1429-48.
    75. Paz SH, Varma R, Klein R, et al. Noncompliance with vision care guidelines in Latinos with type 2 diabetes mellitus: the Los Angeles Latino Eye Study. Ophthalmology 2006;113:1372-7.
    76. Javitt JC, Aiello LP, Bassi LJ, et al. Detecting and treating retinopathy in patients with type I diabetes mellitus. Savings associated with improved implementation of current guidelines. American Academy of Ophthalmology. Ophthalmology 1991;98:1565-73; discussion 1574.
    77. Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy. Ann Intern Med 1996;124:164-9.
    78. Crijns H, Casparie AF, Hendrikse F. Continuous computer simulation analysis of the cost-effectiveness of screening and treating diabetic retinopathy. Int J Technol Assess Health Care 1999;15:198-206.
    79. Quigley HA, West SK, Rodriguez J, et al. The prevalence of glaucoma in a population-based study of Hispanic subjects: Proyecto VER. Arch Ophthalmol 2001;119:1819-26.
    80. Tielsch JM, Katz J, Sommer A, et al. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol 1994;112:69-73.
    81. Wolfs RC, Klaver CC, Ramrattan RS, et al. Genetic risk of primary open-angle glaucoma. Population-based familial aggregation study. Arch Ophthalmol 1998;116:1640-5.
    82. Seah SK, Foster PJ, Chew PT, et al. Incidence of acute primary angle-closure glaucoma in Singapore. An island-wide survey. Arch Ophthalmol 1997;115:1436-40.
    83. Wolfs RC, Grobbee DE, Hofman A, de Jong PT. Risk of acute angle-closure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study. Invest Ophthalmol Vis Sci 1997;38:2683-7.
    84. Nguyen N, Mora JS, Gaffney MM, et al. A high prevalence of occludable angles in a Vietnamese population. Ophthalmology 1996;103:1426-31.
    85. Lai JS, Liu DT, Tham CC, et al. Epidemiology of acute primary angle-closure glaucoma in the Hong Kong Chinese population: prospective study. Hong Kong Med J 2001;7:118-23.
    86. Zhang X, Saaddine JB, Chou C, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA 2010;304:649-56.
    87. Varma R, Torres M, Pena F, et al. Prevalence of diabetic retinopathy in adult Latinos: the Los Angeles Latino eye study. Ophthalmology 2004;111:1298-306.
    88. West SK, Klein R, Rodriguez J, et al. Diabetes and diabetic retinopathy in a Mexican-American population: Proyecto VER. Diabetes Care 2001;24:1204-9.
    89. Klein R, Klein BE, Moss SE, et al. Glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy. JAMA 1988;260:2864-71.
    90. Diabetes Control and Complications Trial Research Group. Progression of retinopathy with intensive versus conventional treatment in the Diabetes Control and Complications Trial. Ophthalmology 1995;102:647-61.
    91. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 2000;342:381-9.
    92. Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes 1995;44:968-83.
    93. Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA 2002;287:2563-9.
    94. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.
    95. Kohner EM, Stratton IM, Aldington SJ, et al. Relationship between the severity of retinopathy and progression to photocoagulation in patients with Type 2 diabetes mellitus in the UKPDS (UKPDS 52). Diabet Med 2001;18:178-84.
    96. Wong TY, Liew G, Tapp RJ, et al. Relation between fasting glucose and retinopathy for diagnosis of diabetes: three population-based cross-sectional studies. Lancet 2008;371:736-43.
    97. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998;317:703-13.
    98. Snow V, Weiss KB, Mottur-Pilson C. The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus. Ann Intern Med 2003;138:587-92.
    99. van Leiden HA, Dekker JM, Moll AC, et al. Blood pressure, lipids, and obesity are associated with retinopathy: The Hoorn Study. Diabetes Care 2002;25:1320-5.
    100. Klein R, Sharrett AR, Klein BE, et al. The association of atherosclerosis, vascular risk factors, and retinopathy in adults with diabetes: the atherosclerosis risk in communities study. Ophthalmology 2002;109:1225-34.
    101. Lyons TJ, Jenkins AJ, Zheng D, et al. Diabetic retinopathy and serum lipoprotein subclasses in the DCCT/EDIC cohort. Invest Ophthalmol Vis Sci 2004;45:910-8.
    102. Klein R, Klein BE, Knudtson MD, et al. Prevalence of age-related macular degeneration in 4 racial/ethnic groups in the multi-ethnic study of atherosclerosis. Ophthalmology 2006;113:373-80.
    103. Varma R, Foong AW, Lai MY, et al. Four-year incidence and progression of age-related macular degeneration: the Los Angeles Latino Eye Study. Am J Ophthalmol 2010;149:741-51.
    104. Klein R, Klein BE, Tomany SC, et al. Ten-year incidence and progression of age-related maculopathy: The Beaver Dam Eye Study. Ophthalmology 2002;109:1767-79.
    105. Varma R, Fraser-Bell S, Tan S, et al, Los Angeles Latino Eye Study Group. Prevalence of age-related macular degeneration in Latinos: the Los Angeles Latino eye study. Ophthalmology 2004;111:1288-97.
    106. Munoz B, Klein R, Rodriguez J, et al. Prevalence of age-related macular degeneration in a population-based sample of Hispanic people in Arizona: Proyecto VER. Arch Ophthalmol 2005;123:1575-80.
    107. Bressler NM, Bressler SB, Fine SL. Age-related macular degeneration. Surv Ophthalmol 1988;32:375-413.
    108. Holz FG, Wolfensberger TJ, Piguet B, et al. Bilateral macular drusen in age-related macular degeneration. Prognosis and risk factors. Ophthalmology 1994;101:1522-8.
    109. Bressler NM, Bressler SB, Seddon JM, et al. Drusen characteristics in patients with exudative versus non-exudative age-related macular degeneration. Retina 1988;8:109-14.
    110. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119:1417-36.
    111. Macular Photocoagulation Study Group. Risk factors for choroidal neovascularization in the second eye of patients with juxtafoveal or subfoveal choroidal neovascularization secondary to age-related macular degeneration. Arch Ophthalmol 1997;115:741-7.
    112. Friedman DS, O'Colmain BJ, Munoz B, et al. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol 2004;122:564-72.
    113. Bressler NM, Bressler SB, Congdon NG, et al, Age-Related Eye Disease Study Research Group. Potential public health impact of Age-Related Eye Disease Study results: AREDS report no. 11. Arch Ophthalmol 2003;121:1621-4.
    114. Tomany SC, Wang JJ, Van Leeuwen R, et al. Risk factors for incident age-related macular degeneration: pooled findings from 3 continents. Ophthalmology 2004;111:1280-7.
    115. Thornton J, Edwards R, Mitchell P, et al. Smoking and age-related macular degeneration: a review of association. Eye 2005;19:935-44.
    116. Khan JC, Thurlby DA, Shahid H, et al. Smoking and age related macular degeneration: the number of pack years of cigarette smoking is a major determinant of risk for both geographic atrophy and choroidal neovascularisation. Br J Ophthalmol 2006;90:75-80.
    117. Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption, omega-3 fatty acid intake, and associations with age-related macular degeneration: the US Twin Study of Age-Related Macular Degeneration. Arch Ophthalmol 2006;124:995-1001.
    118. Fraser-Bell S, Wu J, Klein R, et al. Smoking, alcohol intake, estrogen use, and age-related macular degeneration in Latinos: the Los Angeles Latino Eye Study. Am J Ophthalmol 2006;141:79-87.
    119. Tan JS, Mitchell P, Kifley A, et al. Smoking and the long-term incidence of age-related macular degeneration: the Blue Mountains Eye Study. Arch Ophthalmol 2007;125:1089-95.
    120. Klein R, Knudtson MD, Cruickshanks KJ, Klein BE. Further observations on the association between smoking and the long-term incidence and progression of age-related macular degeneration: the Beaver Dam Eye Study. Arch Ophthalmol 2008;126:115-21.
    121. Clemons TE, Milton RC, Klein R, et al, Age-Related Eye Disease Study Research Group. Risk factors for the incidence of Advanced Age-Related Macular Degeneration in the Age-Related Eye Disease Study (AREDS): AREDS report no. 19. Ophthalmology 2005;112:533-9.
    122. Soubrane G, Cruess A, Lotery A, et al. Burden and health care resource utilization in neovascular age-related macular degeneration: findings of a multicountry study. Arch Ophthalmol 2007;125:1249-54.
    123. Christen WG, Manson JE, Seddon JM, et al. A prospective study of cigarette smoking and risk of cataract in men. JAMA 1992;268:989-93.
    124. Christen WG, Glynn RJ, Ajani UA, et al. Smoking cessation and risk of age-related cataract in men. JAMA 2000;284:713-6.
    125. Sloan FA, Picone G, Brown DS, Lee PP. Longitudinal analysis of the relationship between regular eye examinations and changes in visual and functional status. J Am Geriatr Soc 2005;53:1867-74.
    126. Pollack AL, Brodie SE. Diagnostic yield of the routine dilated fundus examination. Ophthalmology 1998;105:382-6.
    127. Batchelder TJ, Fireman B, Friedman GD, et al. The value of routine dilated pupil screening examination. Arch Ophthalmol 1997;115:1179-84.
    128. American Academy of Ophthalmology. Get your eyes screened at 40: ophthalmologists recommend a check to establish a baseline of eye health. Available at: www.aao.org/eyesmart/know/screening.cfm. Accessed August 27, 2010.
    129. Stelmack JA, Tang XC, Reda DJ, et al, LOVIT Study Group. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126:608-17.
    130. American Academy of Ophthalmology Vision Rehabilitation Committee. Preferred Practice Pattern® Guidelines. Vision Rehabilitation for Adults. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: www.aao.org/ppp.
    131. Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006;124:1754-60.
    132. Frick KD, Gower EW, Kempen JH, Wolff JL. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol 2007;125:544-50.
    133. Taylor HR, Pezzullo ML, Keeffe JE. The economic impact and cost of visual impairment in Australia. Br J Ophthalmol 2006;90:272-5.
    134. Lafuma A, Brezin A, Lopatriello S, et al. Evaluation of non-medical costs associated with visual impairment in four European countries: France, Italy, Germany and the UK. Pharmacoeconomics 2006;24:193-205.


    Christopher J. Rapuano, MD, Chair
    David F. Chang, MD
    Emily Y. Chew, MD
    Robert S. Feder, MD
    Stephen D. McLeod, MD
    Bruce E. Prum, Jr., MD
    R. Michael Siatkowski, MD
    David C. Musch, PhD, MPH, Methodologist

    Academy Staff
    Flora C. Lum, MD
    Nancy Collins, RN, MPH
    Doris Mizuiri
    Medical Editor: Susan Garratt
    Design: Socorro Soberano
    Reviewed by: Council
    Approved by:  Board of Trustees
                         September 11, 2010

    The committee members have disclosed the following financial relationships occurring from January 2010 to September 2010:

    David F. Chang, MD: Alcon Laboratories, Inc. - Consultant/Advisor; Allergan, Inc. - Lecture fees; Calhoun Vision, Inc. - Consultant/Advisor, Equity owner; Eyemaginations, Inc. - Consultant/Advisor, Patent/Royalty; Ista Pharmaceuticals - Consultant/Advisor, Grant support; LensAR - Consultant/Advisor; Hoya - Consultant/Advisor; Revital Vision - Equity owner; SLACK, Inc. - Patent/Royalty; Transcend Medical - Consultant/Advisor

    Emily Y. Chew, MD: No financial relationships to disclose

    Robert S. Feder, MD: Aton Pharma, Inc. - Consultant/Advisor

    Stephen D. McLeod, MD: Abbott Medical Optics - Consultant/Advisor, Equity owner; Visiogen, Inc. - Consultant/Advisor, Equity owner

    David C. Musch, PhD, MPH: Glaukos Corp. - Consultant/Advisor; MacuSight, Inc. - Consultant/Advisor; National Eye Institute - Grant support; NeoVista, Inc. - Consultant/Advisor; Neurotech USA, Inc. - Consultant/Advisor; Oraya Therapeutics, Inc. - Consultant/Advisor; Pfizer Ophthalmics - Grant support; Washington University - Grant support

    Bruce E. Prum, Jr., MD: Alcon Laboratories, Inc. - Grant support; Allergan, Inc. - Consultant/Advisor

    Christopher J. Rapuano, MD: Alcon Laboratories, Inc. - Lecture fees; Allergan, Inc. - Consultant/Advisor, Lecture fees; Bausch & Lomb - Lecture fees; Inspire - Lecture fees; EyeGate Pharma - Consultant/Advisor; Inspire - Lecture fees; Rapid Pathogen Screening - Equity owner; Vistakon Johnson & Johnson Visioncare, Inc. - Lecture fees

    R. Michael Siatkowski, MD: National Eye Institute - Grant support

    Copyright © 2010
    American Academy of Ophthalmology
    All rights reserved

    This document should be cited as:
    American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology, 2010. Available at: www.aao.org/ppp.

    Preferred Practice Patterns are developed by the Academy's H. Dunbar Hoskins Jr., M.D. Center for Quality Eye Care without any external financial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders before publication.


    As a service to its members and the public, the American Academy of Ophthalmology has developed a series of clinical practice guidelines called Preferred Practice Patterns that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care.

    The Preferred Practice Pattern® (PPP) guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.

    Preferred Practice Pattern guidelines provide the pattern of practice, not the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    Preferred Practice Pattern guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U.S. Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. 

    Innovation in medicine is essential to assure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration.

    All PPPs are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the "approved by" date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the document. The PPPs are externally reviewed by experts and stakeholders before publication.

    The intended users of the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern guideline are ophthalmologists.