Naval Submarine Medical Research Laboratory

NSMRL REPORT 1173 31 SEPTEMBER 1991

COMPUTER AIDED OCULAR ASSESSMENT: PROGRAMMER'S MANUAL

by

J. Newacheck

Released by:

R.G. Walter, CAPT, DC, USN

Commanding Officer

Naval Submarine Medical Research Laboratory

Approved for public release; distribution unlimited
Computer Aided Ocular Assessment:

Programmer's Manual

by

James Newacheck

Naval Submarine Medical Research LDaboratory

Report 1173

Naval Medical Research and Development Command

Research Work Unit 63706N M0095.005-5010

Approved and released by:

R. G. WALTER, CAPT, DC, USN

Commanding Officer

NavSubMedRschLab

Approved for public release; distribution unlimited
ii
Summary Page

PROBLEM:

To provide a programmer's reference manual for the Computer Aided Ocular Assessment

(CAOA) program.

FINDINGS:

The manual describes the distributed files and programs included with the CAOA program.

Complete listings of the program code are presented. In addition, selected examples from the

source code are described in detail.

APPLICATION:

The information presented in this manual will allow programmers to modify the CAOA program.

ADMINISTRATIVE INFORMATION

This work was conducted under Naval Medical Research and Development Command Research

Work Unit 63706N-M0095.005-5010, "Submarine deployable computer based system for enhanced medical practice, performance, and quality." The views expressed in this report are those

of the authors and do not reflect the official policy or position of the Department of the Navy,

Department of Defense, or the U.S. Government. This report was approved for publication on

21 September 1991 and has been designated as Naval Submarine Medical Research Laboratory

Report No. 1173.

iii
ABSTRACT

Computer Aided Ocular Assessment (CAOA) is a computer program designed to aid submarine Independent Duty Corpsmen with the diagnosis and treatment of eye disease. This

manual serves as a programmer's reference for the program. It provides complete documentation of all of the program's source code. In addition, selected portions of the code are thoroughly explained.

Expertise with the Exsys Professional expert system development package is required to use

this manual effectively.

iv
Table of Contents

1. INTRODUCTION

2. DESCRIPTION OF DISTRIBUTED PROGRAM FILES

2.1. Exsys Proprietary Files.

2.1.1. Exsysp.exe..

2.1.2. Exsysp.ovl . . .

2.1.3. Exsysp.hlp . . .

2.1.4. Exsysii.exe...

2.1.5. Exii.exe ....

2.1.6. Pager.exe . . .

2.1.7. Num2err.exe . .

2.2. Enter.com ........

2.3. CAOA Specific Files . .

2.3.1. Re7.cfg .....

2.3.2. Re7.cmd ....

2.3.3. Re7.hyt .....

2.3.4. Re7.rpt .....

2.3.5. Re7.rul ....

2.3.6. Re7.scr .....

2.3.7. Re7.txt ......

2.3.8. Shell.* ......

2.3.9. Sorry.scr ....

2.3.10. Sptst.rpt ....

2.3.11. Idx.bat ......

2.3.12. Error.rpt ....

2.3.13. Graphics files .

3. GENERAL RULE STRUCTURE

3.1. Inference Engine ...............

3.2. Knowledge Base ...............

3.3. Condition ...................

3.4. Qualifier ...................

3.5. Values ....................

3.6. Choice ....................

3.7. Confidence Level ...............

3.8. Rules ... ...................

3.9. Forward Chaining ................

4. CUSTOM SCREENS AND HYPERTEXT HELP

4.1. Text Query Screens ...............

4.2. Text Help Screens ..............

4.3. Graphic Help Screens ............

4.4. Text List Screens ...............

v

..................

. . ... . . . . ... . .o .o . . . . . .

. . . . . ., ... . . ... . . o o . .. o .

... . . ... . .. ... .. . . .

. ... .. .. .. . .. . .. o . . . . .

e....e ... . .o . . . . .

. . . . ..... .e.o.e . e . .

.0 ... 0 0 . . . . . . . . . .

. . . . . . . . . . . . . . .

.. . o. . . . ... .e .e .l . . .

. . . . . . . . . . . . ..

... ... ... ... ... ... ... . . . .

. .. .. .. 0 . . . . . . . . .

. . ... .. . . . . . . . . . . . .

.1

.1

.1

.1

.1

.2

.2

.2

.2

.2

.2

.2

.5

.5

.6

.6

.6

.6

.7

.7

.8

.8

.9

.9

.9

.9

10

10

10

10

11

12

12

13

14

16
APPENDIX A: CAOA CONFIGURE AND COMMAND FILES

APPENDIX B: REPORT SPECIFICATION FILES

APPENDIX C: CAOA KNOWLEDGE BASE

APPENDIX D: CAOA SCREEN DEFINITION FILE

APPENDIX E: SHELL CONFIGURE, COMMAND, AND RULE FILES

APPENDIX F

VGA Files (Figs. 1-12) ................................ F-1

EGA Files (Figs. 13-24) ............................... F-8

vi
COMPUTER AIDED OCULAR ASSESSMENT:

PROGRAMMER'S MANUAL

1. INTRODUCTION

The Computer Aided Ocular Assessment

(CAOA) program is designed to aid submarine Independent Duty Corpsmen

(IDC) with diagnosis and treatment of eye

diseases. The purpose of this

programmers manual is to document the

actual program code and to provide a

limited explanation of the code. Companion publications are available which

describe the use of the program (User's

Manual), and the philosophy of the design

and features of the program.

The CAOA program was written using

version 2.0.9 of Exsys Professional, an

expert system development package.

This manual is intended for readers who

are familiar with that package. No attempt is made to replicate information

contained in the Exsys Professional

documentation.

In addition, readers should be familiar

with IBM-PC and compatible computers,

the MS-DOS operating system, and have

some general computer programming

abilities.

In many of the figures that appear

throughout this manual, line numbers are

used for descriptive purposes. It is important to note that line numbers are not used

in any of the actual program code.

2. DESCRIPTION OF DISTRIBUTED

PROGRAM FILES

Because the CAOA program was written

to operate on IBM-PC compatible computers with either EGA or VGA color

monitors, two versions, one for each

monitor type, are currently available.

Notice will be given where files are

specific to one monitor type. The program listings provided in this manual are

all from the VGA version.

2.1. Exsys Proprietary Files

These are files provided by the

manufacturer of the expert system

development package. The

laboratory owns a non-commercial

unlimited runtime license to distribute these files without alteration

of their contents.

2.1.1. Exsysp.exe

This is the main inference engine

program. It works in conjunction

with the overlay file to run existing,

fully developed knowledge bases.

2.1.2. Exsysp.ovl

This is an overlay file that works with

exsysp.exe to reduce memory requirements.

2.1.3. Exsysp.hlp

This is the main help file providing

user assistance for the mechanics of

the Exsys Professional runtime.

2.1.4. Exsysil.exe

This program is used to display

graphic files from outside the Exsys

1
runtime. If the user presses a key

while the image is displayed, the key

value is written to the file is.rtn. Exsysii.exe is called by the idx.bat

batch file.

2.1.5. Ex ii.exe

This program is used from within the

Exsys runtime to display graphics

files. It is called from the re7.scr

screen file.

2.1.6. Pager.exe

This is a utility program that reformats ASCII files. It is called from the

re7.cmd and the *.rpt files. A more

complete description of this program

is available in the file pager.doc

which is located on the original

Exsys diskettes.

2.1.7. Num2err.exe

This is a utility program that sets a

DOS error level based on a

keystroke input by the user.

Num2err.exe sets a DOS error level

equal to the number contained in the

is.rtn file. Num2err.exe is called

from the idx.bat batch file. A more

complete description of this program

is available in the file num2err.doc

which is located on the original

Exsys diskettes.

2.2. Enter.com

This is a public domain utility that

simply transmits a keyboard scan

code simulating the depression of

the enter key. It is called from the

re7.cmd file.

2.3. CAOA Specific Files

These are files created at this

laboratory. They include the

knowledge base, script files that

provide procedural and logical control of the program, graphic and

character-based screens, and

medical user assistance. Files

designated as ASCII were created

using a text editor. All other files

were created using the Exsys

Professional Rule editor.

2.3.1. Re7.cfg

This ASCII script file sets the global

configuration for the CAOA

knowledge base. A listing of the

contents of this file appears in appendix A. Chapter E of the Exsys

manual describes all of the possible

parameters for the configuration file.

Six global parameters are set by the

re7.cfg file. FORWARD specifies

forward chaining of the rules overriding the native backward chaining

mode. RECOVER allows the userto

save and restart a case.

REDISPOFF overrides the display

of files called by the display command when a change and rerun is

ordered by the user. NOTITLE overrides the default exsys generated

character-based knowledge base

title screen. The WHYOFF and

HOWOFF parameters prevent the

user from viewing the knowledge

base rules during a run.

2.3.2. Re7.cmd

Re7.cmd is an ASCII script file that

provides specific procedural control

over the execution of the CAOA pro2
:LOOP

RULES 1-115 /F/N

IF QCHK(51,1)

GOTO LOOP2

ENDIF

IF QCHK(26,1)

GOTO LOOP2

ENDIF

IF QCHK(60,1)

GOTO LOOP2

ENDIF

IF QCHK(32,1)

13

14

15

16

17

18

19

20

21

22

23

24

GOTO LOOP2

ENDIF

IF OCHK(70,1)

GOTO LOOP2

ENDIF

IF OCHK(69,2)

GOTO LOOP3

ENDIF

:LOOP2

REPORT SPTST.RPT

DISPLAY SPTST.SCR

:LOOP3

Figure 1. RE7.CMD Part 1

gram. Chapter J of the Exsys

manual describes the command language in detail. A complete listing of

the command file appears in appendix A.

The first section of the re7.cmd file is

shown in figure 1. It begins with a

marker, :loop, that is used in a goto

statement used later in the command file. When the program is first

started, this marker is skipped over.

In line 2 rules 1-115 are run in forward chaining (IF) mode with no

backward chaining (MN). Next, in

lines 3-17, a series of if-then statements are invoked which determine

whether a special test screen should

be created. These if-then statements test the truth condition of

qualifiers 51, 26, 60, 32, and 70. If

any of these qualifiers are true,

processing jumps to the marker

:loop2, line 21. If a qualifier returns

a false value, its goto statement is

skipped and processing continues in

a linear fashion. Next, qualifier 69 is

tested in line 18 (unless it has been

skipped over by a previous goto

statement). If it returns a true value,

processing jumps over lines 21-23 to

the marker :loop3 in line 24, and the

special test screen is not created. If

qualifier 69 returns a false value the

report generator is called to build the

special test screen using the

sptst.rpt specification file (line 22).

Finally, line 23 displays the special

test screen produced by the report

generator.

The command file continues in figure

2. In line 25, rules 116-161 are run

using forward chaining and no backward chaining (IF IN). Then a series

of if-then statements are tested to

determine if the user has made a

data input error in essentially the

same manner described above. In

lines 26-55, qualifiers 73-76, and 78-

83 are tested. If any of these tests

returns a true value, processing

jumps to :Ioop5, line 57. Line 58

then calls the report generator to

build the error screen specified by

the file error.rpt. The screen created

by the report generator is then displayed by the command in line 59. If

all of the qualifier tests return false

values, the goto statement in line 56

3

1

2

3

4

5

6

7

8

9

10

11

12
RULES 116-161 IF/N

IF OCHK(73,1)

GOTO LOOPS

ENDIF

IF OCHK(74,1)

GOTO LOOPS

ENDIF

IF QCHK(75,1)

GOTO LOOPS

ENDIF

IF OCHK(76,1)

GOTO LOOPS

ENDIF

IF QCHK(78,1)

GOTO LOOPS

ENDIF

IF OCHK(79,1)

GOTO LOOPS

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

ENDIF

IF OCHK(80,1)

GOTO LOOPS

ENDIF

IF OCHK(81,1)

GOTO LOOPS

ENDIF

IF QCHK(82,1)

GOTO LOOPS

ENDIF

IF QCHK(83,1)

GOTO LOOPS

ENDIF

GOTO LOOP6

:LOOP5

REPORT ERROR.RPT

DISPLAY ERROR.SCR

:LOOP6

Figure 2. RE7.CMD Part 2

is invoked and processing jumps to

:loop6, line 60 and the error screen

is not created or displayed.

The final diagnosis screen is created

by the call to the report generator in

line 61, as shown in figure 3. The

screen is then displayed by the command in line 62. After the user is

finished viewing the final diagnosis

screen, qualifier 68 is displayed by

the command in line 64. If the user

selects value 1, Change data and

rerun, the commands in lines 65-69

are invoked. Une 65 checks the

truth condition of value 1 of qualifier

68. If it is found to be true, the screen

is cleared in line 66, enter.com is run

to issue a enter keystroke to the

typematic buffer (this is done to override a decision screen the runtime

module displays by default), the

change data screen is displayed and

processing jumps back to the beginning of the command file. In line 70,

the truth condition of qualifier 68

value 2 is tested. If this test returns

a true value, the current case is

saved and processing jumps to

:loop4, line 63. Finally, in line 74 the

truth condition of qualifier 68 value 3

is tested. If a true value is returned,

61 REPORT RE7.RPT 70 IF OCHK(68,2)

62 DISPLAY SCREEN2.TXT 71 SAVEDATA

63 :LOOP4 72 GOTO LOOP4

64 ASK O 68 73 ENDIF

65 IF OCHK(68,1) 74 IF QCHK(68,3)

66 CLS 75 SAVEDATA

67 RUN ENTER.COM 76 CLEAR ALL

68 CHANGE LOOP 77 GOTO LOOP

69 ENDIF 78 ENDIF

Figure 3. RE7.CMD Part 3

4

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42
the current case is saved, all rules,

qualifiers and variables are cleared

and processing jumps back to the

beginning of the command file. Although it is not explicit in the command file, if value 4 is set for qualifier

68 is set, the command file terminates and control is passed back

to the batch file idx.bat.

2.3.3. Re7.hyt

This file is an index file for the hypertext help facility. It is actually

generated automatically during an

exsys run by the runtime program; it

was not created by the laboratory.

2.3.4. Re7.rpt

This ASCII script file is a report generator specification that builds the

final diagnosis screen. It is called by

the re7.cmd file and produces a file

called screen.txt which is then formatted by pager.exe, producing the

file screen2.txt. Screen2.txt is then

displayed by the re7.cmd command

file.

For descriptive purposes, an abbreviated listing of the Re7.rpt report

specification file appears in figure 4.

The complete listing is reprinted in

appendix B. The first command in

Re7.rpt opens the file screen.txt for

input. In general, lines that contain

the " "/L command simply add a

carriage return line feed to the file.

Lines that contain text surrounded

by quotation marks add the enclosed

text to the screen.txt file. Line 11

contains text formatting instructions

for the pager.exe program. The real

screen building begins with line 12

where all choices are tested to determine if their confidence value equals

or exceeds 100. If the confidence

value of any choice is greater than

or equal to 100, the test returns a true

value and the goto (/G) command is

invoked. Processing jumps to line

14. Then the category label VERY

PROBABLE is added to the

screen.txt file in line 15. In line 16,

the command C=>1 00 /T causes the

report generator to print the text of all

of the choices that received a confidence value greater than or equal

to 100. If no choice confidence

value exceeds or equals 100, the

test in line 12 fails and processing

proceeds to line 13. There, a goto

command is issued which skips over

the category building processes of

lines 14-17, and the VERY PROBABLE category is not created. This

process is repeated two more times

1 FILE SCREEN.TXT 18 :SKIP1

2 a "/L 32 C 0/G:STOP4

4 "CAOA FINAL DIAGNOSES* 35 *Insufficient information for

11 I">eft margin=10" accurate diagnosis." 12 C =100/G:STOP 1 36 :STOP4

13 GOTO SKIPI 43 CLOSE

14 :STOP1 44 RUN pager screen.txt

15 "VERY PROBABLE:" screen2.txt 2 80

16 C =100/T 20 /C

17 "/L

Figure 4. RE7.RPT

5
in lines 19-31 (not shown) to establish similar category listings for

PROBABLE and CONSIDER.

In line 32, another test of the confidence values attained by the

choices is performed. The purpose

of this test is to determine if no choice

received a confidence value of

greater than 0, in which case the

statement 'Insufficient information

for accurate diagnosis' is added to

the screen.txt file. Specifically, line

32 tests whether any choice

received a value of greater than 0. If

so, the goto command is exercised

and processing skips to line 36. If no

choice received a confidence value

greaterthan 0, the test in line 32 fails,

and processing moves to line 35

where the text string is added to the

file. The screen.txt file is closed in

line 43. Then pager.exe is run in the

next line to reformat the screen,

creating the file screen2.txt.

2.3.5. Re7.rul

This file is generated using the

Exsys Professional rule editor. It

contains the text independent

numeric representation of the

knowledge base rules. Chapters B,

C, and D of the Exsys manual explain the fundamentals of rule construction. A complete commented

listing of the rules appears in appendix C, and a detailed description of

rule structure is provided in section

3 of this manual.

2.3.6. Re7.scr

This ASCII file is the screen definition file associated with the CAOA

knowledge base as well as the shell

program. It contains custom

screens which replace all of the

default screens that ask the user for

data for variables. It also contains all

of the hypertext help text screens,

treatment protocol screens, and

calls for graphic help screens.

Chapter I of the Exsys manual

describes the screen definition language in detail. In section 4 of this

document, four of the major screen

types used in the CAOA program are

explained. A complete listing of the

screen definition file appears in appendix D.

Two versions of the re7.scr file have

been produced. One is optimized

for VGA monitors while the other is

optimized for EGA. The only difference between the files is that

graphics calls use different

filenames (see section 2.3.12) and

the graphic mode is set for 16 in the

EGA version and 18 for the VGA

version.

2.3.7. Re7.txt

This file is a companion to the re7.rul

file. It is also generated using the

rule editor. It contains the text portion of the knowledge base rules.

2.3.8. Shell.*

This group of files comprises the

shell program. Shell is a second

expert system that simply provides

the user with direct access to the

treatment protocols and the hypertext help system. The various shell.*

files are directly analogous to the

re7.* files listed above. Listings of all

of the shell files can be found in

appendix E.

6
1 FILE SPTST.SCN

2 a"/L

3 "/L

4 SPECIAL EXAMINATION PROCEDURES"IL

5 a /L

6 "The program is now going to ask about the results of some

7 "procedures you may not have done or may not be familiar with."

8 *Those procedures are:"

9 a UIL

10 ">LEFTMARGIN=1"

11 057 1 FACORNEAL SENSITIVITY MEASUREMENT" /L

12 Q26 1 AAINTRAOCULAR PRESSURE MEASUREMENT"w /L

13 Q60 1 /AACONTACT LENS EXAMINATIONAA" /L

14 032 1 /'VISUAL FIELD EXAMINATIONAA /L

15 070 1 PAAEYEUD EVERSIONAA /L

16 ">LEFTMARGIN=5"

17 "You can use Keyword help to obtain more Information on these

18 "procedures. Simply press until the procedure you are interested

19 "in is displayed at the bottom of the screen, then press the "ENTER" key

20 "to display the information.*

21 close

22 RUN pager sptstscn sptstscr 5 80 20/C

Figure 5. SPTST.RPT

2.3.9. Sorry.scr

This is an ASCII file that is displayed

by the idx.bat file if the user selects

the tutorial option. It explains that

the tutorial is not yet available.

2.3.10. Sptst.rpt

This is another ASCII script file that

contains a report generator

specification. This file is sometimes

called (depending on data input by

the user) by re7.cmd to create a file

named sptst.scn. Sptst.scn is then

formatted by pager.exe, producing

the file sptst.scr which is displayed

by re7.cmd to warn the user that the

program is about to ask for results

from some special test procedure(s).

A complete listing of the sptst.rpt

report specification file appears in

figure 5 and is reprinted in appendix

B. The first command in sptst.rpt

opens the file sptst.scn for input.

Lines 2, 3, 5 and 9 simply add a

carriage return line feed to the file.

Lines 4, 6-8, and 17-20 simply add

the text enclosed in the quotation

marks to sptst.scn. The commands

in lines 10 and 16 are text formatting

parameters used by the pager.exe

program. In lines 11-15 the truth

condition of qualifiers 57, 26, 60, 32,

and 70 is tested. In each case, if

value 1 of the qualifier is true, the test

passes and the quoted text and a

carriage return line feed (/L) are

added to the sptst.scn file. If the

value of a given qualifier is not 1, the

test fails and processing passes to

the next line with no entries in the

sptst.scn file. After all the qualifiers

are tested and the appropriate text is

entered in sptst.scn, the file is closed

by the command in line 21. Finally,

in line 22, the pager.exe program is

run to reformat sptst.scn to create

sptst.scr for screen display.

7
2.3.11. ldx.bat

This is simply a DOS batch file that

displays the preliminary screen and

then the menu screen. Depending

on the user's input, it then calls the

appropriate executable file. After

the user completes a given menu

task, processing control returns to

the batch file which then recycles to

redisplay the menu. A complete listing appears in figure 6.

While most of the commands are

simple DOS commands, a couple of

command line parameters that are

or can be used in the idx.bat file

warrant special attention. The command line parameter maxmem must

be used to override the default condition of the runtime module

whereby it loads the re7.txt and

re7.rul files into memory. This is due

to the extensive use of the note feature to provide programming

documentation for the rules.

Nocolor is another command line

parameter which can be used to optimize the color set used by the runtime

module for LCD displays.

off

REM

cis

exsysii

-IEMCNBLUE.PCX -K'1234' -

M18 -02

:START EXSYSII -ITITLE.PCX - K'1234' -MIS

NUM2ERR

IS.RTN

if errorlevel 4 goto quit

if errorlevel 3 goto tutorial

if errorlevel 2 goto protocols

if errorlevel 1 goto exsys :exsys

Two versions of the idx.bat file have

been produced. One is optimized

for VGA monitors while the other is

optimized for EGA. The only difference between the files is that

graphics calls use different

filenames (see section 2.3.12) and

the graphic mode is set for 16 in the

EGA version and 18 for the VGA

version.

2.3.12. Error.rpt

This is another report specification

file that uses the report generator to

produce a screen to warn the user if

he/she has entered inconsistent

data. It is called by the re7.cmd command file. It produces a screen file

called error.scr which is formatted by

pager.exe to produce the file

error.scr for screen display. This

report specification is similarto those

discussed in sections 2.3.4 and

2.3.10. A complete listing can be

found in appendix B.

SET EXSYS TITLE=(C) EXSYS

Inc., 1988

exsysp re7 maxmem

GOTO START

:protocols

SET EXSYSTITLE=(C) EXSYS

Inc., 1988

exsysp shell maxmem

GOTO START -tutorial

cis

type sorry.scr

pause

GOTO START

:quit

cis

Figure 6. IDX.BAT

8
2.3.13. Graphics files

All of the graphics files are single

screen *.pcx files (PC Paintbrush).

Printouts of all of the graphic files can

be found in appendix F. Most are

scanned images that were edited

using PC Paintbrush IV Plus and

Microsoft Windows Paintbrush.

Separate EGA and VGA versions of

each file were produced:.

contains the computer instructions

to reason with the rules of the

knowledge base.

3.2. Knowledge Base

A knowledge base is a set of rules

that an inference engine uses to

solve a particular problem. In the

case of the CAOA program, the files

re7.rul and re7.txt contain the rules

used to arrive at an ocular diagVGA Filenames

anatomyv.pcx

conjv.pcx

cornsnsv.pcx

dendritv.pcx

emblemv.pcx

eversiov.pcx

fbtrackv.pcx

infiltv.pcx

schiotzv.pcx

titlev.pcx

trigemv2.pcx

visionv.pcx

EGA Filenames

anatomy.pcx

conj.pcx

cornsns.pcx

dendrite.pcx

emcnblue.pcx

eversion.pcx

fbtrack.pcx

inflt.pcx

schiotz.pcx

title.pcx

trigem2.pcx

re.pcx

labeled cross section of human eye

labeled drawing of anterior human eye

diagram of comeal sensitivity test

drawings of herpetic comeal ulcer

NSMRL emblem for preliminary screen

diagram of lid eversion procedure

drawing of foreign body staining

drawing of comeal infiltrate

photo of tonometer procedure

NSMRL emblem with user menu overlay

diagram of trigeminal nerve

refractive eror diagram

3. General Rule Structure

To understand the meaning of rules

created in Exsys Professional, we will

need to define a number of terms: inference engine, knowledge base, condition, value, qualifier, choice, confidence

level, rule, and forward chaining.

3.1. Inference Engine

In Exsys Professional, the inference

engine is embodied in the two files

exsysp.exe and exsysp.ovl. The inference engine is a knowledge independent software program that

nosis. While two other knowledge

base files, shell.rul and shell.txt, are

distributed with the CAOA program,

their purpose is entirely procedural.

3.3. Condition

In Exsys Professional, a condition is

a statement of fact. A condition is

made up of a formula or a qualifier

and one or more values. It may be

textual or mathematical. An example of a text condition from rule

19 of the knowledge base (appendix

C) is, "The condition is affecting

9
both eyes." A text condition may be

true or false, depending on the data

input by the corpsman. A mathematical condition is represented by

an algebraic expression such as

"[lOP OD] > 25" from rule 160, appendix C. The term [lOP OD] is a

variable which stands for intraocular

pressure of the right eye. Mathematical expressions can also be

tested for validity. In this case, the

expression can be tested to determine whether the intraocular pressure of the right eye is or is not

greater than 25 millimeters mercury.

3.4. Qualifier

In general, a qualifier is the part of a

text condition up to and including

the verb. For example, "The condition is affecting" would be the

qualifier for the text condition

described in the previous paragraph. Many of the conditions in the

CAOA rule base are written in the

form of a question. With an interrogative condition, the qualifier is

the part of the condition up to and

including the question mark.

For programming ease, qualifiers

have generally been given names.

This allows the programmer to

quickly locate qualifiers while using

the rule editor. The name consists

of two parts: a designation of the

qualifier type followed by a

mnemonic. The qualifier type

designations are M for metaqualifier, Sx for a symptom query,

and Sn for a sign query. Metaqualifiers represent intermediate

states of knowledge set by the conclusions of some rules. The truth

value of a meta-qualifier is determined by the inference engine from

the rules, not by direct query of the

end user. The meaning of symptom

and sign query is obvious, and their

truth values are set by direct query

of the user.

3.5. Values

For every qualifier, there are at least

two values. Values are the possible

completion of a sentence for declarative conditions. In the case of interrogative conditions, values are

the possible answers to the question posed in the qualifier. Continuing with the example from above,

the possible values attributed to the

qualifier "The condition is affecting"

are "only the right eye", "only the left

eye", and "both eyes".

3.6. Choice

In the CAOA program, a choice corresponds to a diagnosis. The goal

of the expert system is to create a

list of probable choices or diagnoses.

3.7. Confidence Level

A confidence level is a numeric

value associated with a particular

choice which indicates the degree

of confidence that the choice is correct. In Exsys, a confidence level

may be positive or negative and

may have any integer value. In the

CAOA program however, only

values of 50, 30, 20, 10, 0, -10, -20,

-30, and -50 were used. The CAOA

program uses an increment/decrement system to combine the confidence levels assigned to each

10
choice as a result of rules firing.

The inference engine simply sums

the confidence values for each

choice to arrive at a final confidence

level for each diagnoses. The

report specification file re7.rpt then

separates the diagnoses into

categories of "very probable", "probable" and "consider" depending on the final confidence level

achieved by each diagnosis.

3.8. Rules

Rules are the text representation of

the knowledge embedded in the

CAOA program. In general, they

are readable as plain English if-then

statements created from the components described above. All rules

in exsys must have at least two

parts: an IF clause and a THEN

clause. In the CAOA program, all

rules also include a NOTE which

contains programmer's documentation. Two other options which

sometimes appear in CAOA rules

are an ELSE clause and a REFERENCE.

The IF clause of a rule is made up

of one or more conditions. The conditions may be textual or algebraic.

The conditions are statements

which may be true or false, and they

may be connected by the Boolean

operators AND, OR, or NOT. The

inference engine tests the conditions to determine whether the IF

clause of the rule is true or false.

The THEN clause of a rule can contain both conditions and choices

with their associated confidence

levels. Conditions which appear in

the THEN clause of a rule generally

set intermediate knowledge states

which are termed meta-knowledge.

Accordingly, rules that contain only

conditions in the THEN clause are

called meta-rules. When the inference engine determines that the

IF clause of a rule is true, it sets all

of the conditions in the THEN clause

of the rule to true and increments or

decrements all of the choices accordingly. Conversely, when the IF

clause of a rule is found to be false,

all of the conditions in the THEN

clause are set to false, but the

choices are neither incremented nor

decremented; they are simply ignored.

The ELSE clause of a rule is optional. ELSE functions like THEN except the ELSE conditions are

instantiated as true and the ELSE

choices are incremented/decremented when the IF clause of the

rule is found to be false. ELSE is

used sparingly in the CAOA program because when ELSE exists in

a rule, some part of the rule is always true. That is, when ELSE exists, the rule will always have some

effect on the diagnostic outcome.

NOTEs are used primarily to document the purpose and logic of individual rules. This feature is used

extensively in the CAOA knowledge

base.

A REFERENCE can also be added

to a rule. This feature was seldom

utilized in the CAOA knowledge

base because the sources of

knowledge were intermixed and

profoundly filtered by the developer.

11
3.9. Forward Chaining

Also known as data-directed

search, forward chaining is a mode

of rule execution where rules are

fired in essentially the order they

occur in the knowledge base. In a

forward chaining system, rule firing

is also controlled by the current

knowledge state, i.e. the data accumulated at a given point in time.

This is in contrast to backward

chaining, which is the default mode

of Exsys Professional. With backward chaining, a particular goal (i.e.

diagnosis) is assumed, and appropriate rules are fired in an order

determined by the inference engine

to prove or disprove that goal. Then

a second goal is assumed, it is

proved or disproved and so on, until

each goal is tested.

All rules in the CAOA program are

run in a forward chaining mode.

While a forward chaining system is

much harder to implement, it offers

one major advantage over a backward chaining system: the order of

query is completely controllable.

Thus, it is possible to build an expert

system that interrogates the user in

a planned and natural way. In the

CAOA program, user questioning

follows the standard medical SOAP

format.

4. Custom Screens and Hypertext Help

Custom screens are special replacements for the screens the Exsys program

builds to display queries. Hypertext help

screens are also custom screens used for

displaying information in response to the

user's help request. There are four

general types of custom screens used in

the CAOA program: text query screens;

text help screens; graphic help screens;

and text list screens. All custom screens

and hypertext help screens are contained

in the file re7.scr which is listed in appendix D.

4.1. Text Query Screens

In its default mode, when it came

time to query the user about his

patient's visual acuity, Exsys

Professional would display a screen

reading "Input a value for the variable: Visual Acuity, OD." A custom

screen was needed to provide more

specific information about what was

being asked as well as to query the

user in a more natural way. An example of the text query screen that

replaces the default screen for variable 3 is shown in figure 7.

In the Exsys Professional screen

definition language, the tilde (-)

character is used as a marker to

designate commands, hypertext

keywords, and qualifier and variable

names or numbers. The first entry

in figure 7 is -V3 which serves as

the header forthe screen that will be

used to replace the default screen

for variable 3. Lines 2-6 designate

the background and text colors for

the text that follows. The text of the

replacement screen appears in

lines 7-20. This is simply ASCII text

with a CR-LF at the end of each line.

In general, to avoid undesirable

color effects, it is best to extend

each line of the text to column 79

with spaces before inserting the

CR-LF. A red border with the text

"Exsys Pro" overlaying the upper

right comer is created by the commands in lines 21-24. A dark blue

12
1 -V 3

2 -CLS

3 -BACKGROUND LTCYAN

4 -COLOR BLACK

5 -CLS

6 -CURSET 0,0

7

8

9

10 VISUAL ACUITY OD

11

12 Please enter the best corrected distance visual acuityof the

13 right eye:

14

15

16

17

18 VIA OD: 20/

19

20

21 -BORDER 0,2,21,78, RED

22 -Color BLUE

23 -CURSET 0,4

24 EXSYS PRO

25 -CURSET 22,0

26 -BACKGROUND BLUE

27 -COLOR WHITE

28 Enter the value for visual acuity and press

29 ?-details Quit-save H-help -Keyword

30 -CURSET 11,42

Figure 7.

status bar is created at the bottom

of the screen by the commands in

lines 25-26. The text of the status

bar is overlaid in lines 28-29. Finally, in line 30, the cursor position is

reset so the blinking cursor will appear in the appropriate position for

data entry.

4.2. Text Help Screens

Exsys Professional provides the

facility for generating a hypertext

help system. Hypertext is essentially a richly cross-referenced text

file which allows instant access to

any hypertext keyword highlighted

on screen. Text help screens include screens for word definitions,

instructions for specific procedures,

and treatment protocols. An abbreviated example of a hypertext

help screen definition appears in figure 8.

The help screen is defined in essentially the same manner as the custom screen described in the

previous section. There are a few

differences, however. A double

tilde is used as a marker for hypertext keywords, as shown in line 1 of

figure 8. The command SAMEAS is

used to link synonymous keywords

such as "myopia" and "high myopia"

so that separate screens need not

be created. Another departure from

the custom screen format is the use

of boxes to mark off separate sections of text. These boxes, created

13
1 -- high myopia

2 -SAMEAS myopia

3 -- myopia

4 -BACKGROUND BLUE

5 -CLS

10 -COLOR WHITE

11 High Myopia

12

13 DEFINITION: High myopia is a condition where the axial length

14 of the eye is too long for the optics of the eye.

15 For the purposes of this program, high myopia is defined

16 as refractive error exceeding -3.00 diopters (e.g. -4.OOD).

17 For more discussion about the nature of myopia, see the

18 screen on AArefractive error AA.

21

22 BACKGROUND: Because myopic eyes are generally larger

23 than average, their retinas tend to be stretched compared

24 to non-myopic eyes. This sutetching of the retina is

25 thought to increase the likelihood of AAretinal breaks"

26 and AAvitreous detachmentsA.

29

30 -BORDER 2,2,21,78, CYAN

31 -Color CYAN

32 -CURSET 2, 5

33 MEDIC Hypertext Help System

34 -BORDER 5,10,12,70, CYAN

35 -BORDER 13,10,19,70, CYAN

Figure 8. Excerpt from RE7.SCR

by the commands in lines 34-35 are

created in the same way the border

is made. Finally, with hypertext

help screens, there is no need for

commands to draw the status bar at

the bottom of the screen because

the status bar is created automatically by the Exsys Professional runtime program.

4.3. Graphic Help Screens

In some cases it is desirable to include a graphic screen to illustrate

a test procedure or to provide more

background on word definitions.

This facility is accomplished by calls

for graphic help screens in the form

of *.pcx files.

As shown in figure 9, the command

for calling a graphic screen is quite

simple. In line 1, the hypertext

keyword is identified with a double

tilde. The graphic screen is called

in line 2 with the command IMAGE.

The format of the command is

IMAGE(filename.ext -K'\[acceptable keys]' -M[graphic mode number]). In this case, the IMAGE

command would load the file

comsnsv.pcx, allow the use of the

enter key only, and display the file

using graphics mode 18

(640X480X16 colors). A complete

description of all of the IMAGE command parameters is provided in

chapter N of the Exsys Professional

manual.

Exsys Professional always expects

a text screen to be displayed immediately after a graphic screen. Accordingly, in lines 3-21 a text screen

is defined in exactly the same way

as a text help screen except there is

14
I -- corneal sensitivity test

2 -I MAGE(CORNSNS.pcx -K\N' -M16)

3 -BACKGROUND BLUE

4 -CLS

5

6

7

8

9 -COLOR WHITE

10 Corneal Sensitivity Test

11

12 REVIEW METHOD: To measure comeal sensitivity, make a

13 cotton wisp from a cotton tipped applicator by pulling 14 some of the cotton swab from each of two applicators.

15 The goal is to create two applicators each with a single

16 fiber of cotton extending from the tip.

17

18 -BORDER 2,2,22,78, CYAN

19 -Color CYAN

20 -CURSET 2,5

21 MEDIC Hypertext Help System

22 -BORDER 5,10,11,73, CYAN

Figure 9. Excerpt from RE7.SCR

1 -0 "always true*

2 -CLS

3 -COLOR WHITE

4 -BACKGROUND BLUE

5 -CLS

6 TREATMENT PROTOCOLS

7

8 Use the F1 key to select the treatment protocol you wish

9 to view, then press

10

11 Acute Angle Closure GlaucomaAA

12

13 AAcute IritisAA

14

15 "Allergic Conjunctivitis^"

16

17 "Bacterial Conjunctivitis"

18

19 AABlepha•tSAA

20

21 AChalazionAA

22

23 AChronic IntisA

24

25 AContact Lens TearA

26

27 "Contact Lens Depos^tAA

28 -PRESS ANY KEY

Figure 10. Excerpt from RE7.SCR

15
no need to redesignate the hypertext keyword.

4.4. Text List Screens

Direct access to treatment protocols

is provided by the Shell.* program

and a text list screen. The text list

screen resides in the file re7.scr

along with all the other custom

screens. The text list screen shown

in figure 10 is very similar to a text

help screen. It's purpose is simply

to display a list of hypertext

keywords corresponding to the

available treatment protocols. A

similar approach could be used to

provide direct access to a glossary

of terms, but this feature was not

implemented in the current version

of CAOA.

Acknowledgements:

Special thanks are due to Captain

Douglas M. Stetson, MC, USN for his

support and guidance throughout this

project. Many of the program's better

features are a direct result of his suggestions. All of the graphics contained in the

CAOA program were ably created by

HM1 Todd Brewer, USN. HM1 Brewer

also offered a number of useful comments from the users perspective that

helped to make CAOA a better program.

16
Appendix A

CAOA Configure and Command Files
RE7.CFG File

FORWARD

RECOVER

REDISPOFF

NOTITLE

WHYOFF

HOWOFF

RE7.CMD File

:LOOP

RULES 1-115/F/N

IF QCHK(51,1)

GOTO LOOP2

ENDIF

IF QCHK(26,1)

GOTO LOOP2

ENDIF

IF QCHK(60, 1)

GOTO LOOP2

ENDIF

IF QCHK(32,1)

GOTO LOOP2

ENDIF

IF QCHK(70,1)

GOTO LOOP2

ENDIF

IF QCHK(69,2)

GOTO LOOP3

ENDIF

:LOOP2

REPORT SPTST.RPT

DISPLAY SPTST.SCR

:LOOP3

RULES 116-161 /F/N

IF QCHK(73,1)

GOTO LOOP5

ENDIF

IF QCHK(74,1)

GOTO LOOP5

ENDIF

IF QCHK(75,1)

GOTO LOOP5

ENDIF

IF QCHK(76,1)

GOTO LOOP5

ENDIF

IF QCHK(78,1)

GOTO LOOP5

ENDIF

IF QCHK(79,1)

GOTO LOOP5

ENDIF

IF QCHK(80,1)

GOTO LOOP5

ENDIF

IF QCHK(81,1)

GOTO LOOP5

ENDIF

IF QCHK(82,1)

GOTO LOOP5

ENDIF

IF QCHK(83,1)

GOTO LOOP5

ENDIF

GOTO LOOP6

:LOOP5

REPORT ERROR.RPT

DISPLAY ERROR.SCR

:LOOP6

REPORT RE7.RPT

DISPLAY SCREEN2.TXT

:LOOP4

ASK Q 68

IF QCHK(68,1)

CLS

RUN ENTER.COM

CHANGE LOOP

ENDIF

IF QCHK(68,2)

SAVEDATA

GOTO LOOP4

ENDIF

IF QCHK(68,3)

SAVEDATA

CLEAR ALL

GOTO LOOP

ENDIF

Appendix A-2
Appendix B

Report Specification Files
FILE SCREEN.TXT

" "/L

""L

"CAOA FINAL DIAGNOSES"

"The final conclusions of the program are displayed below. They are"

"grouped in three categories: 'Very Probable,' 'Probable,' and 'Consider."'

"You should treat all diagnoses within a given category as equally likely,"

"and at least consider each of the diagnoses displayed."

" "/L ">>left margin=1 0"

C>=100 /G:STOP1

GOTO SKIP1

:STOP1

"VERY PROBABLE:"

C>=100 /T

" "/L

:SKIP1

C>=50<1 00 /G:STOP2

GOTO SKIP2

:STOP2

"PROBABLE:"

C>=50<100 /T

" "/L

:SKIP2

C>5<50 /G:STOP3

GOTO SKIP3

:STOP3

"CONSIDER:"

C>5<50 /T

:SKIP3

C>0 /G:STOP4

"/L

"/L

"Insufficient information for accurate diagnosis."

:STOP4 ">>left-margin=2"

"/L

" You can use Keyword Information <Fl> to display treatment advice for" "any of the diagnoses listed. Simply press <Fl> until the disease you are"

"interested in is displayed at the bottom of the screen, then press the" "<ENTER> key to display the treatment information."

CLOSE

RUN pager screen.txt screen2.txt 2 80 20/C

Appendix B-2
SPTST.RPT file

FILE SPTST.SCN ""/L

" "/L

"SPECIAL EXAMINATION PROCEDURES"/L

" "/L

"The program is now going to ask about the results of some" "procedures you may not have done or may not be familiar with."

"Those procedures are:"

" "/L ">>LEFT MARGIN=1 5"

057 1 /"^ACORNEAL SENSITIVITY MEASUREMENTAA" /L

026 1 /"AAINTRAOCULAR PRESSURE MEASUREMENTAA" /L

Q60 1 /^AACONTACT LENS EXAMINATIONAA" /L

032 1 /"AAVISUAL FIELD EXAMINATIONAA" /L

Q70 1 /"AAEYELID EVERSIONA" /L ">>LEFT MARGIN=5"

"You can use Keyword help <Fl> to obtain more information on"

"these procedures. Simply press <Fl> until the procedure you are"

"interested in is displayed at the bottom of the screen, then"

"press the <ENTER> key to display the information."

close

RUN pager sptst.scn sptst.scr 5 80 20 /C

ERROR.RPT File

FILE ERROR.SCN

" "/L

" "/L

"INCONSISTENT DATA WARNING"/L

" "/L

"Some of the data you have entered into the program may"

"be inconsistent with any of the diseases the program considers."

"Those inconsistencies are:"

" "/L

Q73 1I" You said the condition was affecting the left"

073 1 /"eye, but you also indicated that pressure was high"

Q73 1 Pin the right eye."I/L

Q74 1 " You said the condition was affecting the right"

Appendix B-3
074 1 Peye, but you also indicated that pressure was high"

Q74 1 Pin the left eye." /L

Q75 1 P You said the condition was affecting the left"

Q75 1 /"eye, but you also indicated that fields were abnormal"

075 1 /"in the right eye." /L

Q76 1 P You said the condition was affecting the right" Q76 1 /"eye, but you also indicated that fields were abnormal"

076 1 Pin the left eye." /L

Q78 1 /" You said the cornea was normal, but also indicated"

078 1 /"that you saw corneal staining. Usually, if"

Q78 1 /"staining is present, you can see some corneal abnormality." /L

079 1 /" You entered high intraocular pressure readings for"

Q79 1 /"both eyes. This finding would be highly unlikely" Q79 1 /"with any of the conditions the program considers." /L

Q80 1 /" You indicated that visual fields were abnormal for"

Q80 1 Pboth eyes. This finding would be highly unlikely"

080 1 /"with any of the conditions the program considers." /L

081 1 /" You said the condition was affecting the left"

081 1 /"eye, but you also indicated that the right pupil" 081 1 /"was abnormal." /L

082 1 /" You said the condition was affecting the right"

Q82 1 /"eye, but you also indicated that the left pupil"

Q82 1 /"was abnormal."/L

083 1 /" You indicated that the pupils were abnormal for'

Q83 1 /"both eyes. This finding would be highly unlikely" Q83 1 /"with any of the conditions the program considers." /L

" "/L

"Inconsistencies may indicate a data entry error or they" "may imply that your patient's condition is beyond the scope of"

"this program. If you suspect a data entry error, you can use"

"the Change and Rerun feature which is available after the"

"diagnosis screen."

close

RUN pager ERROR.scn ERROR.scr 5 80 20/C

Appendix B-4
Appendix C

CAOA Knowledge Base
Subject:

Computer Aided Ocular Assessment for Submarine Independent Duty

Corpsmen

Author:

Naval Submarine Medical Research Laboratory

Starting text:

This program is a PROTOTYPE of a computer aided diagnosis module for

submarine Independent Duty Corpsmen. As such, its diagnostic accuracy has not been verified. It should not be used for actual medical diagnosis.

This program is the property of the Naval Submarine Medical Research

Laboratory and may not be copied or distributed without written permission

from the Commanding Officer.

Ending text: The progam is about to produce a list of possible diagnoses ordered from most to least likely. The numbers attached to a given diagnosis

provide a relative scaling of the likelihood of that diagnosis. However, any of

the diagnoses are possible. Only the corpsman can determine the correct

final diagnosis.

Because this program is an untested prototype,

DO NOT RELY ON THIS PROGRAM FOR ACCURATE DIAGNOSES!

Uses all applicable rules in data derivations.

Probability System: Increment/decrement

DISPLAY THRESHOLD: 5

QUALIFIERS:

Appendix C-2
Does your patient complain of any of the following symptoms of AAvisual

disturbanceA^?

Blurred or decreased vision

AADouble visionAA

AADistorted visionAA

AAFlashing lightsAA

AAFloatersAA

AAHaloes around lightsAA

None of the above

Name: Sx Visual

Used in rule(s): 0001 0002

2 Does your patient complain of any ^^irritationAA?

Itching

Scratchy or foreign body sensation

Pain

Burning

AAPhotophobiaAA

None of the above

Name: Sx Sensory

Used in rule(s): 0005

0012

0118

0003 0004 0112 0113

of the following symptoms of. ocular

0006 0007 0008 0009

0090 0112 0114 01

0119

3 How does your patient rate the itching

Mild

Moderate

Severe

None of the above

0010

16 0117

symptom?

Name: Sx Itch Degree

Maximum acceptable = 1

Used in rule(s): 0006

4 How does your patient rate the symptom of pain?

Mild

Moderate

Severe

Appendix C-3
None of the above

Name: Sx Pain Degree

Used in rule(s): 0008

5 Does your patient complain of any of these other ocular symptoms?

Redness

Discharge (other than tearing)

Excessive tearing

Lids stuck together upon arising

None of the above

Name: Sx Other Ocula

Used in rule(s): 0011 0013 0014 0067 0068 0069

0070 0071 0123

6 The condition is affecting:

Only the right eye

Only the left eye

Both eyes

Name: Sx Lateralityl

Maximum acceptable = 1

Used in rule(s): 0018 0019 0041 0042 0043 0044

0045 0046 0047 0048 0132 0133

0135 0136 0137 0138 0139 0140

0141 0142 0143 0144 0153 0154

0155 0156 0157 0158

7 The condition is:

Unilateral

Bilateral

Name: M Laterality2

Used in rule(s): (0018) (0019) 0020 0021

8 Is there an ^^associated history of ocular traumaA?

Yes

No

Appendix C-4
Name: Hx Trauma Y/N

Maximum acceptable = 1

Usedin rule(s): 0022 0023 0113 0150

9 Does your patient have an ocular history of any of the following?

Previous ocular herpes infections

AAHigh MyopiaAA (spectacle Rx <-4.OOD)

AAHigh HyperopiaAA (spectacle Rx > +3.OOD)

Recent or current soft contact lens wear

Recent or current hard or gas permeable contact lens wear

None of the above

Name: Hx Oc Msc 1

Used in rule(s): 0024 0025 0026 0027 0028 0029

0030 0111 0112 0113 0121

10 Does your patient wear the lenses on an extended wear (overnight) basis?

Yes

No

Name: Hx CL EW

Maximum acceptable = 1

Used in rule(s):

11 Does your patient have a significant medical history of any of the following

conditions?

Allergies (hay fever, etc.)

Genital or Labial Herpes Venereal disease

Connective tissue disorder (arthritis, etc.) Recent or current URI

None of the above

Name: Hx Med

Used in rule(s): 0034 0035 0036 0037 0111 0112

Appendix C-5
12 The AAonsetAA of symptoms can best be described as:

Sudden

Acute

Chronic

Name: Sx Onset

Maximum acceptable = 1

Used in rule(s): 0015 0016

13 The patient's lids appear to be:

Normal

Abnormal

Name: Sn Lids 1

Maximum acceptable = 1

Used in rule(s): 0049

0055

0050

0056

14 Are any of the following abnormalities

lashes?

Crusted material on lash line

AAInduratedAA (hard or firm) mass

AAErythemaAA

AAEdemaAA

AAEczematousAA flaking of lid skin

None of the above

0017 0113

0051 0052 0053 0054

present in your patient's lids and

Name: Sn Lids 2

Used in rule(s): 0050 0051 0052 0053 0054 0055

0056

15 The mass is:

AATenderAA

AANon-tenderAA

Name: Sn Lids 3

Maximum acceptable = 1

Used in rule(s): 0051 0052

Appendix C-6
16 The AAconjunctivaAA appears to be:

Normal

Abnormal

Name: Sn Conj 1

Maximum acceptable = 1

Used in rule(s): 0057

0063

0069

0075

0058

0064

0070

0076

0059

0065

0071

0077

17 Are any of the following conjunctival AARednessAA

AAEdemaAA

AAFolliclesAA

AAPapillaeAA

None of the above

Name: Sn Conj 2

Used in rule(s): 0058

0064

0059

0065

abnormalities present?

0060

0066

0061

(0080)

0062

0122

18 The location of the conjunctival injection can

AADiffuseAA

AACircumcornealAA

AASectorialAA

Name: Sn Conj 3

Maximum acceptable = 1

Used in rule(s): 0058 0059 0060

19 How would you rate the degree of the

Mild

Moderate

Severe

Name: Sn Conj 4

Maximum acceptable = 1

Used in rule(s): 0061

best be described as:

AAconjunctival rednessAA?

0062 0063

Appendix C-7

0060

0066

0072

0080

0061

0067

0073

0090

0062

0068

0074

0122

0063

0123
20 Are any of the following conjunctival discharges present? AA Excessive tearing AA

AAStringyAA

AAMucoidAA

AAMucopurulentAA

AAPurulentAA

None of the above

Name: Sn Disch

Used in rule(s): 0067 0068 0069 0070 0071

21 Were you able to obtain a conjunctival smear?

Yes

No

Name: Sn Conj Sm

Maximum acceptable = 1

Used in rule(s): 0072 0073 0074 0075 0076 0077

22 Did the conjunctival smear reveal abnormal amounts of any

cell types? AANeutrophilsAA

AAEosinophilsAA

AALymphocytesAA

AAMonocytesAA

Bacteria

None of the above

Name: Sn Conj Sm2

Used in rule(s): 0072 0073 0074 0075 0076 0077

23 What type(s) of bacteria were present?

Gram-positive cocci

Gram-negative cocci

Gram-negative rods

None of the above

Name: Sn Conj Sm3

Used in rule(s): 0076 0077

Appendix C-8

of the following
24 Were you able to obtain AAlntraocular pressureAA readings from your patient?

Yes

No

Name: Sn lOP Y/N

Maximum acceptable = 1

Used in rule(s): 0134

0140

0135

0147

0136

0148

0137

0155

0138

0156

0139

0160

25 What were the results of your evaluation of A^tactile tensionsAA?

Both eyes equal and normal

Right eye firmer than left

Left eye firmer than right

None of the above / test not performed

Name: Sn TT

Maximum acceptable = 1

Used in rule(s): 0135 0136 0148

26 lOP should:

Be evaluated

Not be evaluated

Name: M lOP Eval

Used in rule(s): (0112)

0137

0155

[0112]

0138

0156

0115

0139

0160

0134

0140

0135

0147

0136

0148

27 The pupillary size and

Normal, both eyes

Abnormal, right eye

Abnormal, left eye

Abnormal, both eyes

response to light appear to be:

Name: Sn Pupil N/Ab

Maximum acceptable = 1

Used in rule(s): 0040

0046

0154

0041

0047

0042

0048

0043

0112

0044

0152

Appendix C-9

0045

0153
28 The pupillary response to light of the right eye is:

Normal

Sluggish

Absent

Name: Sn Pup Res OD

Maximum acceptable = 1

Used in rule(s): 0041 0045

29 The pupillary response to light

Normal

Sluggish

Absent

of the left eye is:

Name: Sn Pup Res OS

Maximum acceptable = 1

Used in rule(s): 0042 0046 0048

30 The size of the right pupil is (as compared to the left):

Normal

Constricted

Dilated

Name: Sn Pup Sz OD

Maximum acceptable = 1

Used in rule(s): 0043 0047

31 The size of the left pupil is (as

Normal

Constricted

Dilated

Name: Sn Pup Sz OS

Maximum acceptable = 1

Used in rule(s): 0044

32 confrontation VF

Should be done

Should not be done

compared to the right):

Appendix C- 10
Name: M VF Eval

Used in rule(s): (0113) [0113]

0144 0157

0115

0158

33 What were the results of your AAvisual field

Normal

AAGeneral constriction of the visual fieldAA

AASectorial defectAA

0141

0161

0142 0143

examinationAA of the RIGHT eye?

Name: Sn VF Defect

Maximum acceptable = 1

Used in rule(s): 0141 0143

34 What were the results of your AAvisual field examinationAA of the LEFT eye?

Normal

AAGeneral constriction of the visual fieldAA

AASectorial defectAA

Name: Sn VF OS

Maximum acceptable = 1

Used in rule(s): 0142 0144

35 What were the results of the ^^visual field examination^A?

Normal, both eyes

Abnormal, right eye Abnormal, left eye Abnormal, both eyes

Name: Sn Vf Exam

Maximum acceptable = 1

Used in rule(s): 0141 0142 0143 0144 0157 0158

0161

36 OD vision is:

Normal

Reduced

Name: M VA OD N/Ab

Appendix C- 11
Used in rule(s): (0038) [0038] 0120

37 OS Vision is:

Normal

Reduced

Name: M VA OS N/Ab

Used in rule(s): (0039) [0039]

38 What did your examination of

Normal

AAPalpable and non-tenderAA

AAPalpable and tenderAA

Name: Sn PA Nodes

Maximum acceptable = 1

Used in rule(s): 0078

39 The cornea is:

Normal

Abnormal

Name: Sn Cor N/Ab

Maximum acceptable = 1

Used in rule(s): 0081

0087

0159

the AApre-auricular nodesAA Reveal?

0079 0111

0082

0088

0083

0089

0084

0090

0085

0092

0086

0149

40 Are any of the following corneal abnormalities present?

Cloudy or hazy appearance

Scratch or abrasion

AALocalized edematous areaAA

AAInfiltratesAA (Gray or white patches)

Foreign body present

None of the above

Name: Sn Cor 2

Used in rule(s): 0081

0087

0082

0088

0083

0089

0084

0105

0085 0086

0149

Appendix C- 12

0120
41 Which of the following choices best describes the appearance of the

abraded area?

Clean and sterile

Adherant greenish ^AdischargeAA or AAexudateAA

Adherant white discharge or exudate

None of the above

Name: Sn Cor Abr

Maximum acceptable = 1

Used in rule(s): 0084 0085 0086 0088 0089

42 Were you able to obtain a AAGram's stainAA of the AAexudateAA from the site

of corneal involvement?

Yes

No

Name: Sn Cor G Stn Y

Maximum acceptable = 1

Used in rule(s): 0085 0086

43 What were the results of the AAGram's stainAA of the corneal AAexudateAA?

G+ Cocci

G- Cocci

G- Rods

None of the above

Name: Sn Cor G Stn 2

Maximum acceptable = 1

Used in rule(s): 0085 0086

44 Does the cornea exhibit A*fluorescein staining^A?

Yes

No

Name: Sn Cor Fl St Y

Maximum acceptable = 1

Used in rule(s): (0091) 0092 0093 0094 0095 0096

0097 0098 0099 0100 0101 0102

0103 0104 0111 0150

Appendix C- 13
45 The size of the area(s) of corneal staining can best be described as:

Punctate (pinpoint)

Less than 1 mm

Larger than 1 mm

Name: Sn Cor Stn Sz

Used in rule(s): 0096 0097 0098

46 There is:

Punctate Corneal Staining

No Punctate Corneal Staining

Name: M Cor Stn Pct

Used in rule(s): (0096) [0096] 0106 0124

47 The stained area is:

Less than 1 mm

Not less than 1 mm

Name: M Cor Stn

Used in rule(s): (0097) [0097] 0151

48 The area of staining is:

Larger than 1 mm

Not larger than 1 mm

Name: M Cor Stn 1

Used in rule(s): (0098) [0098] 0105 0151 0159

49 The amount of corneal staining is best characterized as:

A single area

2 to 3 areas

Multiple areas

Name: Sn Cor Stn Amt

Maximum acceptable = 1

Used in rule(s): 0099 0100 0101

50 Staining is:

Appendix C- 14
Only in one area

Not only in one area

Name: M Stn Amt 1

Used in rule(s): (0099) [0099]

51 The staining is:

In 2-3 areas

Not in 2-3 areas

Name: M Stn Amt 2-3

Used in rule(s): (0100) [0100]

52 The location of the corneal staining is best characterized as:

Central

Peripheral

AADiffuseAA

Name: Sn Stn Loc

Maximum acceptable = 1

Used in rule(s): 0102 0103 0104

53 Stain location is:

Central

Not central

Name: M Stn Loc Cen

Used in rule(s): (0102) [0102]

54 The stain location:

Is peripheral

Is not peripheral

Name: M Stn Loc Peri

Used in rule(s): (0103) [0103] 0121

Appendix C- 15
55 The stain location is:

Diffuse

Not diffuse

Name: M Stn Loc Diff

Used in rule(s): (0104) [0104] 0106 0124 0151

56 The stain amt is:

Multiple areas

Not multiple areas

Name: M Stn Amt Mult

Used in rule(s): (0101) [0101] 0105 0124 0151

57 Corneal sensitivity should:

Be measured

Not be measured

Name: M Cor Sen Y/N

Used in rule(s): (0111) [0111] 0115 0131 0132 0133

58 What were the results of the A^Corneal sensitivity testAA?

Both corneas are about equally sensitive

Right cornea more sensitive than left

Left cornea more sensitive than right.

Name: Sn Cor Sen Maximum acceptable = 1

Used in rule(s): 0131 0132 0133

59 Do you feel that your patient's

Yes

No

Not sure

problem is contact lens related?

Name: Sn CL

Related Maximum acceptable = 1

Used in rule(s): 0027 0028 0029

Appendix C- 16
60 The problem is:

CL Related

Not CL Related

Name: M CL Related

Used in rule(s): (0027)

0033

0054

0075

0107

0114

0120

0126

0146

(0028)

0049

0055

0076

0108

0115

0121

0127

(0029)

0050

0056

0077

0109

0116

0122

0128

(0030)

0051

0072

0078

0111

0117

0123

0129

0031

0052

0073

0079

0112

0118

0124

0130

0032

0053

0074

0083

0113

0119

0125

0145

61 The peripheral corneal staining is predominantly:

Superior

Inferior

Lateral

None of the above

Name: Sn Cor Stn Per

Used in rule(s): 0121

62 Has your patient changed any of his AAcontact lens care solutionsAA to new

brands in the past month?

Yes

No

Name: Sn CL Sol Chg

Maximum acceptable = 1

Used in rule(s): 0031

63 Is your patient using any contact

Yes

No

Name: Sn CL Sol Pres

Maximum acceptable = 1

Used in rule(s): 0032

lens care solutions with ^^preservatives^A?

0033

Appendix C- 17
64 Inspection of the contact lens (removed from the eye) reveals:

AADepositsAA

AADamaged edgeAA

AAInverted lensAA

None of the above

Name: Sn CL Insp

Usedinrule(s): 0125 0126 0127 0128 0129 0130

65 Which part of the cornea appears cloudy or hazy?

Superior one-third

Middle one-third

Inferior one third

Entire cornea

Name: Sn Cor Hz Loc

Maximum acceptable = 2

Used in rule(s): 0082 0083

66 The AAanterior chamberAA is:

Normal

Abnormal

Name: Sn A/C N/Abn

Maximum acceptable = 1

Used in rule(s): 0107 0108 0109 0110

67 Are any of the following AAanterior chamberAA abnormalities present?

A/C contains blood

A/C contains pus AAAqueus humorAA appears cloudy

None of the above

Name: Sn A/C Abn

Used in rule(s): 0107 0108 0109

Appendix C- 18
68 Would you like to:

Change data and rerun the program

Save this case

Start a new patient encounter

Exit the diagnostic module

Name: X 1

Maximum acceptable = 1

Used in rule(s):

69 SPTST.SCR should

Be displayed

Not be displayed

Name: M SCR 1

Used in rule(s): (0115)

70 Lid eversion should:

Be performed

Not be performed

Name: M Lid 1

Maximum acceptable = 1

Used in rule(s): (0114) [0114] 0115 0145 0146 0149

71 AAEversionAA of the eyelids reveals:

AAPapillaeAA (bumpy or velvety appearance to upper tarsal conjunctiva)

Foreign body

Inflammation

None of the above

Name: Sn Lid Evert

Used in rule(s): 0145 0146 0149

72 Fluorescien staining should:

Be done

Not be done

Appendix C- 19
Name: M Cor Stn

Maximum acceptable = 1

Used in rule(s): (0090) [0090] 0091 0092 0093 0094

0095 0096 0097 0098 0099 0100

0101 0102 0103 0104 0150 0151

0159

73 LAT OS, lOP HIGH OD:

Warn

Don't warn

Used in rule(s): (0155) [0155]

74 Laterality OD, High lOP OS:

Warn

Don't warn

Used in rule(s): (0156) [0156]

75 Visual field abnormal OD, laterality OS:

Warn

Don't warn

Used in rule(s): (0157) [0157]

76 Visual field abnormal OS, laterality OD:

Warn

Don't warn

Used in rule(s): (0158) [0158]

77 Does the staining pattern match either of these patterns? AADendriticAA (branching)

AAForeign body trackingAA (zig-zag)

None of the above

Name: Sn Cor stn pat

Used in rule(s): (0091) 0093 0094 0095 0096 0097

0098 0099 0100 0101 0102 0103

0104 0151

Appendix C-20
78 Cornea normal, staining abnormal:

Warn

Don't warn

Used in rule(s): (0159) [0159]

79 High lOP OU:

Warn

Don't warn

Used in rule(s): (0160) [0160]

80 VF Abnormal OU:

Warn

Don't warn

Used in rule(s): (0161) [0161]

81 Pupil ABN RT, Laterality LEFT:

Warn

Don't warn

Used in rule(s): (0154) [0154]

82 Pupil abnormal left, laterality right:

Warn

Don't warn

Used in rule(s): (0153) [0153]

83 Pupils abnormal OU:

Warn

Don't warn

Used in rule(s): (0152) [0152]

84 Consider lid eversion:

Yes

No

Used in rule(s): (0094) [0094] 0114

Appendix C-21
CHOICES:

1 AAPneumococcal corneal ulcerAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0012) (0015) (0016) (0017) (0021) (0057)

(0067) (0072) (0076) (0081) (0084) (0085)

(0086) (0088) (0089) (0092) (0093) (0094)

(0105) (0108) (0151)

2 AAPseudomonas corneal ulcerAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0012) (0015) (0016) (0017) (0021) (0057)

(0067) (0072) (0077) (0081) (0084) (0085)

(0086) (0088) (0089) (0092) (0093) (0094)

(0105) (0108) (0151)

3 AAHerpes simplex keratitisAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0012) (0013) (0015) (0016) (0017) (0021)

(0025) (0035) (0057) (0067) (0074) (0079)

(0088) (0089) (0092) (0093) (0095) (0131)

(0132) (0133)

4 AACorneal abrasionAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0011) (0012) (0013) (0015) (0016) (0017)

(0021) (0022) (0057) (0067) (0081) (0084)

(0085) (0086) (0088) (0089) (0092) (0093)

(0105) (0151)

5 AATraumatic iritisAA

Used in rule(s): (0007) [0007] (0008) (0009) (0013) (0015)

(0016) (0017) (0021) (0022) (0023) (0040)

(0041) (0042) (0043) (0044) (0047) (0048)

(0057) (0058) (0067) (0109) (0139) (0140)

Appendix C-22
6 AAAcute iritisAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0013) (0016) (0017) (0021) (0036) (0040)

(0041) (0042) (0043) (0044) (0047) (0048)

(0057) (0058) (0067) (0109) (0139) (0140)

7 AAChronic iritisAA

Used in rule(s): (0003) (0007) [0007] (0008) (0009) (0010)

(0013) (0015) (0016) (0017) (0021) (0036)

(0040) (0041) (0042) (0043) (0044) (0047)

(0048) (0057) (0058) (0067) (0109) (0139)

(0140)

8 AAAcute angle closure glaucomaAA

Used in rule(s): (0002) (0003) (0007) [0007] (0008) (0010)

(0013) (0015) (0016) (0017) (0021) (0026)

(0040) (0041) (0042) (0043) (0044) (0045)

(0046) (0047) (0048) (0057) (0058) (0067)

(0082) (0115) (0134) (0135) (0136) (0137)

(0138) (0143) (0144) (0147) (0148)

9 AARetinal detachmentAA

Used in rule(s): (0001) [0001]

(0016) (0017)

10 AABacterial conjunctivitisAA

Used in rule(s): (0003) (0006)

(0013) (0014)

(0057) (0059)

(0075) (0078)

11 AAViral conjunctivitisAA

Used in rule(s): (0003) (0006)

(0013) (0014) (0056) (0057)

(0003) (0010) (0013) (0015)

(0022) (0024) (0141) (0142)

(0008) (0009) (0010) (0012)

(0015) (0016) (0017) (0056)

(0064) (0070) (0071) (0072)

(0079)

(0008) (0010) (0011) (0012)

(0015) (0016) (0017) (0037)

(0059) (0064) (0066) (0067)

Appendix C-23
(0069) (0070) (0071) (0074) (0078) (0079)

(0106)

12 AAAllergic conjunctivitisAA

Used in rule(s): (0003) (0004) (0005) [0005] (0006) (0008)

(0009) (0010) (0011) (0012) (0014) (0015)

(0016) (0017) (0034) (0055) (0057) (0059)

(0061) (0064) (0065) (0066) (0067) (0068)

(0071) (0073) (0145) (0146)

13 AAChalazionAA

Used in rule(s): (0008) (0009) (0012) (0013) (0015) (0016)

(0017) (0049) (0051) (0052) (0053) (0054)

14 AAHordeolumAA

Used in rule(s): (0009) (0012) (0015) (0016) (0017) (0021)

(0049) (0051) (0052) (0053) (0054) (0055)

15 AABlepharitisAA

Used in rule(s): (0003) (0008) (0009) (0012) (0015) (0016)

(0017) (0020) (0049) (0050) (0054) (0055)

(0056)

16 AASubconjunctival hemorrhageAA

Used in rule(s): (0003) (0015) (0016) (0017) (0022) (0057)

(0060) (0061) (0062) (0063)

17 AACorneal foreign bodyAA

Used in rule(s): (0010) (0011) (0015) (0016) (0017) (0022)

(0087) (0094) (0149) (0150)

18 Contact lens induced AAGiant papillary conjunctivitisAA

Used in rule(s): (0116) (0119) (0120) (0122) (0123) (0146)

Appendix C-24
19 Contact lens induced AASuperior limbic conjunctivitisAA

Used in rule(s): (0083) (0116)

(0123)

20 AAContact lens solution allergyAA

Used in rule(s): (0003) (0031) (0032)

(0118) (0123) (0124)

(0117) (0118) (0120) (0121)

(0033) (0116) (0117)

21 AAContact lens depositAA

Used in rule(s): (0119) (0120) (0123) (0125) (0128)

22 AAInverted contact lensAA

Used in rule(s): (0119) (0120) (0127) (0129)

23 AADamaged contact lensAA

Used in rule(s): (0119) (0126) (0130)

24 AAHyphemaAA

Used in rule(s): (0107) (0110)

FORMULAS:

1 [VAOD] <25

Used in rule(s):

2 [VA OS] < 25

Used in rule(s):

3 [IOP OD] > 0

Used in rule(s):

0038

0039

0134

Appendix C-25
4 [IOP OS] > 0

Used in rule(s): 01

5 [lOP OD] > 30

Used in rule(s): 01

6 [lOP OS] < 25

Used in rule(s): 01

7 [lOP OS] > 30

Used in rule(s): 01

8 [lOP OD] <25

Used in rule(s): 01

9 [lOP OD] < 25

Used in rule(s): 01

10 [lOP OS] <25

Used in rule(s): 01

11 [lOP OD] < ([lOP OS]-2)

Used in rule(s): 01

12 [lOP OD] < 25

Used in rule(s): 01

13 [lOP OS] < 25

Used in rule(s): 0140

34

37

37

38

38

39

39

39

40

Appendix C-26
14 [lOP OS] < ([lOP OD] -2)

Used in rule(s):

15 [IOP OD] < 25

Used in rule(s):

16 [IOP OS] < 25

Used in rule(s):

17 [lOP OD] > 25

Used in rule(s):

18 [IOP OS] <25

Used in rule(s):

19 [lOP OD] < 25

Used in rule(s):

20 [IOP OS] <25

Used in rule(s):

21 [IOP OD] >25

Used in rule(s):

22 [lOP OS] >25

Used in rule(s):

23 [CASE NO]= [DX]

Used in rule(s):

0140

0147

0147

0155

0155

0156

0156

0160

0160

0162

Appendix C-27
VARIABLES:

1 IOP OD

Enter the intraocular pressure of the RIGHT eye

Numeric variable

Used in rule(s): 0134 0137 0138 0139 0140 0147

0155 0156 0160

2 IOP OS

Enter the intraocular pressure of the LEFT eye

Numeric variable

Used in rule(s): 0134 0137 0138 0139 0140 0147

0155 0156 0160

3 VAOD

Enter the AAcorrected visual acuityAA for the RIGHT eye (just enter the

denominator or second number of the snellen fraction. i.e. for 20/40, just

enter 40).

Numeric variable

Used in rule(s): 0038

4 VAOS

Enter the AAcorrected visual acuityAA for the LEFT eye (just enter the

denominator or second number of the snellen fraction. i.e. for 20/40, just

enter 40).

Numeric variable

Used in rule(s): 0039

5 CASE NO

Poise database case no

String variable

Used in rule(s): 0162

6 DX

Providers diagnosis

String variable

Used in rule(s): 0162

Appendix C-28
RULES:

RULE NUMBER: 1

IF:

Does your patient complain of any of the following symptoms of AAvisual

disturbance^A? AAFlashing lights^^ OR ^^Floaters^^

THEN:

AARetinal detachmentAA - Confidence=30

ELSE:

AARetinal detachmentAA - Confidence=-30

NOTE:

Flashes and/or floaters are probably the only clue an IDC will have to indicate the possibility of retinal detachment. Both the presence and absence of

these symptoms are highly indicative of the possibility of retinal detachment.

Thus, the presence of either or both of these symptoms increments (+30) to

the retinal detachment register. Conversely, the absence of both of these

symptoms decrements the retinal detachment register by (-30).

RULE NUMBER: 2

IF:

Does your patient complain of any of the following symptoms of AAvisual

disturbanceAA? AAHaloes around lightsAA

THEN:

AAAcute angle closure glaucomaAA - Confidence=1 0

NOTE:

Severe corneal edema, common with angle closure glaucoma, causes the

symptom of Haloes around point sources of light. The symptom may or may

not be present with AACG and it may be present with other diseases which

affect the clarity of the ocular media. So, only (+10) is incremented to the

AACG register in the presence of the symptom while the absence of the

symptom has no effect on the AACG register.

Appendix C-29
RULE NUMBER: 3 IF:

Does your patient complain of any of the following symptoms of ^^visual

disturbanceA^? ^^Distorted vision^^

THEN:

^^Retinal detachment^^ - Confidence=1 0

andA"Pneumococcal corneal ulcer^^ - Confidence=-1 0

and ^^Pseudomonas corneal ulcer^^ - Confide nce=-1 0

and ^^Herpes simplex keratitis^^ - Confidence=-1 0

and ^^Corneal abrasion^AA- Confidence=-1 0

and ^^Acute iritis^^ - Confidence=-1 0

and ^^Chronic iritis^^ - Confidence=-1 0

and ^^ct angle closure glaucoma^^ - Confidence=-1 0

and ^^Bacterial conjunctivitis^^ - Confidence=-1 0

and ^^Viral conjunctivitis^^ - Confidence=-1 0

and ^^Allergic conjunctivitis"" - Confidence=-1 0

and ^^Blepharitis^^ - Confidence=-1 0

and ^^Subconjunctival hemorrhage^^ - Confidence=-1 0

and ^^Contact lens solution allergy^^ - Confidence=-10

NOTE:

The presence of metamorphopsia is indicative of a retinal disorder. Retinal

detachment is the only disease considered by the program that is likely to

cause metamorphopsia, hence its register is incremented +10 if the

symptom is present. All other diseases are decremented -10 if metamorphopsia is present as it is an unlikely finding in all cases other than retinal

disorders.

REFERENCE:

Roy p. 519

RULE NUMBER: 4

IF:

Does your patient complain of any of the following symptoms of ^^visual

disturbance"^? Blurred or decreased vision

THEN:

^^Allergic conjunctivitis^^~ - Confidence=-1 0

Appendix C-30
NOTE:

Blurred vision may or may not be present in virtually all of the diseases the

program considers. Therefore, it is not a useful symptom to base differential

diagnoses on. The presence of blurred vision can be used to help exclude

certain conditions, however. For example, blurred vision is an unlikely finding in allergic conjunctivitis, so the allergic conjunctivitis register is decremented (-10) in the presence of blurred vision.

RULE NUMBER: 5

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Itching

THEN:

AAAllergic conjunctivitisAA - Confidence=1 0

ELSE:

AAAllergic conjunctivitisAA - Confidence=-1 0

NOTE:

The presence of itching is nearly pathonogmonic for allergy. Therefore, the

presence of itching (without regard to severity) causes a small (+10) incremental change to the allergic conjunctivitis register. The absence of itching (at any severity) is suggestive that allergic conjunctivitis is not likely so

that register is decremented (-10) in the absence of itching.

RULE NUMBER: 6

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Itching and How does your patient rate the itching symptom? Moderate OR Severe

THEN:

AAAllergic conjunctivitisAA - Confidence=20

and AABacterial conjunctivitisAA - Confidence=-10

and AAViral conjunctivitisAA - Confidence=-1 0

NOTE:

If the degree of itching is moderate to severe, the impact of the symptom is

Appendix C-31
more clearly suggestive of allergic conjunctivitis, thus the allergic conjunctivitis register is further incremented by (+20). Because viral and bacterial conjunctivitis are frequently in the differential, and the presence of

moderate to severe itching is mildly suggestive that they are not reasonable

diagnoses, their register values are decremented (-10).

RULE NUMBER: 7

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Pain

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas corneal ulcerAA - Confidence=1 0

and AAHerpes simplex keratitisAA - Confidence=1 0

and AACorneal abrasionAA - Confidence=1 0

and AATraumatic iritisAA - Confidence=1 0

and AAAcute iritisAA - Confidence=10

and AAChronic iritisAA - Confidence=10

and AAAcute angle closure glaucomaAA - Confidence=10

ELSE:

AAPneumococcal corneal ulcer AA- Confidence=-1 0

and AAPseudomonas comeal ulcerAA - Confidence=-10

and AAHerpes simplex keratitisAA - Confidence=-1 0

and AACorneal abrasionAA - Confidence=-1 0

and AATraumatic iritisAA - Confidence=-1 0

and AAAcute iritisAA - Confidence=-1 0

and AAChronic iritisAA - Confidence=-1 0

and AAAcute angle closure glaucomaAA - Confidence=-1 0

NOTE:

The symptom of pain (without regard to severity) is common to many of the

diseases the program considers. In addition, pain, especially mild pain, is

often an uncorrelated finding. Therefore, in the presence of pain, the appropriate register values are incremented minimally. In the absence of pain,

the registers are decremented minimally.

Appendix C-32
RULE NUMBER: 8

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Pain

and How does your patient rate the symptom of pain? Moderate OR

Severe

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas comeal ulcerAA - Confidence=1 0

and AAHerpes simplex keratitisAA - Confidence=1 0

and AACorneal abrasionAA - Confidence=1 0

and AATraumatic iritisAA - Confidence=1 0

and ^^Acute iritisAA - Confidence=1 0

and AAChronic iritisAA - Confidence=10

and AAAcute angle closure glaucomaAA - Confidence=10

and AABacterial conjunctivitisAA - Confidence=-1 0

and AAViral conjunctivitisAA - Confidence=-1 0

and AAAllergic conjunctivitisAA - Confidence=-30

and AAChalazionAA - Confidence=-1 0

and AABlepharitisAA - Confidence=-1 0

NOTE:

If the degree of pain is moderate to severe, the reliability of the patient's complaint is enhanced. This allows a further increment of (+10) in the presence of moderate to severe pain. Some diseases, such as allergic conjunctivitis would be highly unlikely if the patient complained of severe or moderate

pain. Thus, they are decremented appropriately if this rule is true.

RULE NUMBER: 9

IF:

Does your patient complain of any of the following symptoms of ocular

*^irritationAA? ^^Photophobia^^

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas corneal ulcerAA - Confidence=10

and AAHerpes simplex keratitisAA - Confidence=1 0

and AACorneal abrasionAA - Confidence=10

Appendix C-33
and AATraumatic iritisAA - Confidence=10

and AAAcute iritisAA _ Confidence=10

and AAChronic iritisAA - Confidence=10

and AABacterial conjunctivitisAA - Confidence=-10

and AAAllergic conjunctivitisAA - Confidence=-1 0

and AAChalazionAA - Confidence=-1 0

and AAHordeolumAA - Confidence=-1 0

and AABlepharitisAA - Confidence=-1 0

NOTE:

Photophobia is a symptom common to all diseases affecting the cornea

and/or iris. It is another symptom that is often present idiopathically, however. Therefore, the presence of photophobia provides a minimal incremental effect to the registers of corneal and iris related diseases. It also causes

a minimal decremental effect to the registers of those diseases which do not

normally affect the cornea.

RULE NUMBER: 10

IF:

Does your patient complain of any of the following symptoms of ocular

^^irritation^A? Scratchy or foreign body sensation

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas corneal ulcerAA - Confidence=1 0

and AAHerpes simplex keratitisAA - Confidence=1 0

and AACorneal abrasionAA - Confidence=1 0

and AABacterial conjunctivitisAA - Confidence=1 0

and AAViral conjunctivitisAA - Confidence=10

and AAAllergic conjunctivitisAA - Confidence=1 0

and AAAcute iritisAA - Confidence=-1 0

and AAChronic iritisAA - Confidence=-1 0

and AAAcute angle closure glaucomaAA - Confidence=-1 0

and AARetinal detachmentAA - Confidence=-1 0

and AACorneal foreign bodyAA - Confidence=10

NOTE:

A scratchy or foreign body sensation is a vague symptom of irritation that is

often present in inflamed eyes. It may be due to chemosis, discharge, corneal compromise, and of course, a foreign body. Thus, this symptom is of

minimal value in the differential. The registers of diseases that are likely to

Appendix C-34
cause this symptom are incremented (+10) while the registers of those diseases which generally do not cause a scratchy sensation are decremented

minimally (-10). The absence of this symptom is probably not indicative of

anything, so no else condition is used in this rule.

RULE NUMBER: 11

IF:

Does your patient complain of any of these other ocular symptoms?

Excessive tearing

THEN:

AACorneal abrasionAA - Confidence=1 0

and AAViral conjunctivitisAA - Confidence=10

and AAAllergic conjunctivitisAA - Confidence=1 0

and AACorneal foreign bodyAA - Confidence=10

NOTE:

The symptom of excessive tearing is indicative of a corneal problem or allergic conjunctivitis. Thus the registers of common corneal problems and allergic conjunctivitis are incremented (+10) if this symptom is present.

RULE NUMBER: 12

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Burning

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas comeal ulcerAA - Confidence=1 0

and AAHerpes simplex keratitisAA - Confidence=1 0

and AACorneal abrasionAA - Confidence=1 0

and AAViral conjunctivitisAA - Confidence=10

and AABacterial conjunctivitisAA - Confidence=-1 0

and AAAllergic conjunctivitisAA - Confidence=-1 0

and AAChalazionAA - Confidence=-1 0

and AAHordeolumAA - Confidence=-1 0

and AABlepharitisAA - Confidence=-1 0

Appendix C-35
NOTE:

A burning sensation is often a vague description of pain. This symptom is of

little value in the differential, therefore the effect of the presence of a burning

sensation is to minimally increment diseases of corneal compromise and to

minimally decrement those other diseases which are likely to be in the differential.

RULE NUMBER: 13

IF:

Does your patient complain of any of these other ocular symptoms?

Discharge (other than tearing)

THEN:

AAHerpes simplex keratitisAA - Confidence=-1 0

and AACorneal abrasionAA - Confidence=-1 0

and AATraumatic iritisAA - Confidence=-1 0

and AAAcute intisAA - Confidence=-1 0

and AAChronic iritisAA - Confidence=-1 0

and AAAcute angle closure glaucomaAA - Confidence=-1 0

and AARetinal detachmentAA - Confidence=-1 0

and AABacterial conjunctivitisAA - Confidence=1 0

and AAViral conjunctivitisAA - Confidence=10

and AAChalazionAA - Confidence=-1 0

NOTE:

The presence of a discharge (other than tearing) is generally indicative of an

external infection of the eye. Thus, Bacterial and Viral conjunctivitis are incremented +10 in the presence of a discharge (without regard to type, i.e.

purulent, mucoid, etc.) while diseases that are generally internal or non-infectious are decremented -10 if a discharge is present. If the symptom is absent, there is no effect on any disease register because the symptom may

be subclinical. The corpsman will be further queried about discharge character in the examination section of the program.

RULE NUMBER: 14

IF:

Does your patient complain of any of these other ocular symptoms? Lids

stuck together upon arising

Appendix C-36
THEN:

AABacterial conjunctivitisAA - Confidence=30

and AAViral conjunctivitisAA - Confidence=-1 0

and AAAllergic conjunctivitisAA - Confidence=-1 0

NOTE:

If sufficient mucopurulent exudate is produced to cause this symptom, bacterial conjunctivitis is almost certain. Therefore, in the presence of this

symptom, the bacterial conjunctivitis register is incremented +30. The

registers for allergic and viral conjunctivitis are decremented -10 as they are

likely to be in the differential. The absence of this symptom causes no effect

on any disease register, as it may not be present early in the disease

process.

RULE NUMBER: 15

IF:

The AAonsetAA of symptoms can best be described as: Sudden

THEN:

AARetinal detachmentAA - Confidence=1 0

and AAChronic intisAA - Confidence=-1 0

and AACorneal abrasionAA - Confidence=1 0

and AATraumatic iritisAA - Confidence=1 0

and AAAcute angle closure glaucomaAA - Confidence=10

and AAPneumococcal corneal ulcerAA - Confidence=-1 0

and AAPseudomonas comeal ulcerA^ - Confidence=-1 0

and AAHerpes simplex keratitisAA - Confidence=-1 0

and AABacterial conjunctivitisAA - Confidence=-1 0

and AAViral conjunctivitisAA - Confidence=-1 0

and AAAllergic conjunctivitisAA - Confidence=-1 0

and AAChalazionAA - Confidence=-1 0

and AAHordeolumAA - Confidence=-1 0

and AABlephantisAA - Confidence=-1 0

and AASubconjunctival hemorrhage^^ - Confidence=10

and AACorneal foreign bodyAA - Confidence=1 0

NOTE:

The onset of symptoms is a good means of differentiating the various diseases the program considers. The quality of the patient's and corpsman's

communication skills can affect the validity of the input greatly, however.

Appendix C-37
Thus, this symptom is used to differentiate between all diseases considered

but any one disease register is affected only mildly by the onset finding.

RULE NUMBER: 16

IF:

The ""onset"" of symptoms can best be described as: Acute

THEN:

""^Pneumococcal corneal ulcer"A - Confidence=1 0

and ""Pseudomonas corneal ulcer"" - Confidence=1 0

and ""Herpes simplex keratitis"" - Confidence=10

and ""Corneal abrasionA" - Confidence=1 0

and ""Traumatic iritisA" - Confidence=1 0

and ""Acute iritisA" - Confidence=1 0

and ""Chronic iritisA" - Confidence=0

and AAAcute angle closure glaucoma"" - Confidence=10

and ""Retinal detachmentA" - Confidence=0

and ""Bacterial conjunctivitisA" - Confidence=1 0

and ""Viral conjunctivitis"" - Confidence=1 0

and ""Allergic conjunctivitisA" - Confidence= 10

and ""Chalazion"A - Confidence=-1 0

and ""Hordeolum"" - Confidence=1 0

and ""Blepharitis"" - Confidence=0

and ""Subconjunctival hemorrhage"" - Confidence=0

and ""Corneal foreign body"" - Confidence=0

NOTE:

The onset of symptoms is a good means of differentiating the various diseases the program considers. The quality of the patient's and corpsman's

communication skills can affect the validity of the input greatly, however.

Thus, this symptom is used to differentiate between all diseases considered

but any one disease register is affected only mildly by the onset finding.

RULE NUMBER: 17

IF:

The ""onset"" of symptoms can best be described as: Chronic

Appendix C-38
THEN:

""^Pneumococcal corneal ulcer"A - Confidence=-1 0

and ""Pseudomonas corneal ulcer"" - Confidence=-1 0

and ""Herpes simplex keratitis"" - Confidence=-1 0

and ""Corneal abrasion"" - Confidence=-1 0

and ""Traumatic intis"" - Confidence=-1 0

and ""Acute iritis"" - Confidence=-1 0

and ""Chronic iritis"" - Confidence=1 0

and ""Acute angle closure glaucoma"" - Confidence=-1 0

and ""Retinal detachment"" - Confidence=0

and ""Bacterial conjunctivitis"" - Confidence=-10

and ""Viral conjunctivitis"" - Confidence=0

and ""Allergic conjunctivitis"" - Confidence=0

and AAChalazionAA - Confidence=1 0

and ""Hordeolum"" - Confidence=-1 0

and ""Blepharitis"" - Confidence=10

and ""Subconjunctival hemorrhage"" - Confidence=-1 0

and ""Corneal foreign body"" - Confidence=-1 0

NOTE:

The onset of symptoms is a good means of differentiating the various diseases the program considers. The quality of the patient's and corpsman's

communication skills can affect the validity of the input greatly, however.

Thus, this symptom is used to differentiate between all diseases considered

but any one disease register is affected only mildly by the onset finding.

RULE NUMBER: 18

IF:

The condition is affecting: Only the right eye or: The condition is affecting: Only the left eye

THEN:

THE CONDITION IS UNILATERAL

NOTE:

The purpose of this rule is to provide a shorthand notation for laterality for

use in later rules. The program only needs to consider unilateral vs. bilateral

presentations in making diagnoses. Left and right information is collected for

reporting purposes.

Appendix C-39
RULE NUMBER: 19

IF:

The condition is affecting: Both eyes

THEN:

THE CONDITION IS BILATERAL

NOTE:

The purpose of this rule is to provide a shorthand notation for laterality for

use in later rules. The program only needs to consider unilateral vs. bilateral

presentations in making diagnoses. Left and right information is collected for

reporting purposes.

RULE NUMBER: 20

IF:

THE CONDITION IS UNILATERAL

THEN:

""^Blepharitis"" - Confidence=-20

NOTE:

Blepharitis is almost always unilateral, thus if the corpsman inputs a

unilateral presentation, the blepharitis register is decremented (-20).

RULE NUMBER: 21

IF:

THE CONDITION IS BILATERAL

THEN:

""^Pneumococcal corneal ulcer"" - Confidence=-20

and ""Pseudomonas corneal ulcer"" - Confidence=-20

and ""Herpes simplex keratitis"" - Confidence=-20

and ""Corneal abrasion"" - Confidence=-1 0

and ""Traumatic iritis"" - Confidence=-1 0

and ""Acute iritis"" - Confidence=-1 0

and ""Chronic iritis"" - Confidence=-1 0

Appendix C-40
and ""Acute angle closure glaucoma"" - Confidence=-1 0

and ""Hordeolum"" - Confidence=-1 0

NOTE:

While many of the diseases can occur bilaterally, corneal ulcers, abrasions,

iritis, etc. usually don't. It is fairly unlikely that a comeal ulcer would cause

significant bilateral symptomology, thus each of the ulcer registers are decremented moderately (-20). It is also unlikely, but not impossible, that iritis

would present bilaterally, thus the iritis registers are decremented slightly (-

10) if the symptoms are bilateral. Although the anatomical features which

predispose angle closure glaucoma are bilateral, pupillary block seldom occurs simultaneously in both eyes, thus the acute glaucoma register is decremented slightly (-10) if the condition is bilateral. While retinal detachment is

seldom bilateral at onset, the symptomology can be confusing to the patient.

It is often difficult for him to determine with certainty that photopsia is occurring in only one eye. Thus the retinal detachment register is unaffected by

laterality. Corneal abrasions generally are unilateral.

RULE NUMBER: 22

IF:

Is there an ""associated history of ocular trauma""? Yes

THEN:

""^Retinal detachment"" - Confidence=20

and ""Traumatic iritis"" - Confidence=20

and ""Subconjunctival hemorrhage"" - Confidence=10

and ""Corneal abrasion"" - Confidence=1 0

and AACorneal foreign body"" - Confidence=10

NOTE:

Trauma can induce a retinal detachment. Retinal detachment is therefore

more likely in patients who have experienced trauma. Trauma can also induce a traumatic iritis and to a lesser extent, a subconjunctival hemorrhage.

Thus, if this rule fires, the RD and traumatic iritis registers are incremented

(+20) and the subconjunctival hemorrhage register is incremented (+10).

The presence of trauma does not affect any other disease register.

Appendix C-41
RULE NUMBER: 23

IF:

Is there an ""associated history of ocular trauma"A? No

THEN:

""^Traumatic iritis"" - Confidence=-50

NOTE:

By definition, traumatic iritis can not occur in the absence of trauma. If this

rule fires, its register is decremented (-50). Other conditions such as RD and

subconjunctival hemorrhage can occur in the absence of trauma, so this rule

has no effect on their registers.

RULE NUMBER: 24

IF:

Does your patient have an ocular history of any of the following? ""^High Myopia"" (spectacle Rx <-4.OOD)

THEN:

"^Retinal detachment"" - Confidence=20

NOTE:

High myopia is a sign of an elongated eye with a stretched retina. Retinal

detachment is more likely in patients with high myopia. The presence of

high myopia does not affect any other disease register.

RULE NUMBER: 25

IF:

Does your patient have an ocular history of any of the following?

Previous ocular herpes infections

THEN:

""^Herpes simplex keratitis"" - Confidence=30

NOTE:

A history of ocular herpes infections is strongly suggestive of the possibility

Appendix C-42
the current condition is herpes keratitis because herpes is a recurrent condition. Thus, this rule adds a value of +30 to the herpes register if true.

RULE NUMBER: 26

IF:

Does your patient have an ocular history of any of the following? ""*High Hyperopia"" (spectacle Rx > +3.00D)

THEN:

""*Acute angle closure glaucoma" A- Confidence=20

NOTE:

The finding of high hyperopia is indicative of a small eye which is more susceptible to angle closure than an average or large sized eye. Hyperopia has

no significant effect on other disease registers. If high hyperopia is present,

the AACG register is incremented moderately (+20). The absence of this

finding may often be attributable to lack of previous diagnoses (i.e. latent hyperopia) or inadequate medical records. Thus, the absence of this sign has

no effect on the AACG register.

RULE NUMBER: 27

IF:

Does your patient have an ocular history of any of the following?

Recent or current soft contact lens wear OR Recent or current hard or

gas permeable contact lens wear and Do you feel that your patient's

problem is contact lens related? Yes

THEN:

THE PROBLEM IS CL RELATED

NOTE:

The purpose of this and some following rules is to determine whether the

patient's condition is related to the wearing of contact lenses. The effect of

these rules is to create a major branch point in the questioning strategy. If

the corpsman inputs that the problem is CL related, the physical examination

questions will be directed toward a contact lens diagnoses. If the corpsman

feels that the problem is not CL related, the PE questions will be directed to

a non-CL diagnoses. If the corpsman is not sure, the program will examine

Appendix C-43
both possibilities. In any case, these rules prevent the program from considering a CL related diagnosis if the patient is not a CL wearer.

RULE NUMBER: 28

IF:

Does your patient have an ocular history of any of the following?

Recent or current soft contact lens wear OR Recent or current hard or gas

permeable contact lens wear

and Do you feel that your patient's problem is contact lens related? No

THEN:

THE PROBLEM IS NOT CL RELATED

NOTE:

The purpose of this and some following rules is to determine whether the

patient's condition is related to the wearing of contact lenses. The effect of

these rules is to create a major branch point in the questioning strategy. If

the corpsman inputs that the problem is CL related, the physical examination

questions will be directed toward a contact lens diagnoses. If the corpsman

feels that the problem is not CL related, the PE questions will be directed to

a non-CL diagnoses. If the corpsman is not sure, the program will examine

both possibilities. In any case, these rules prevent the program from considering a CL related diagnosis if the patient is not a CL wearer.

RULE NUMBER: 29

IF:

Does your patient have an ocular history of any of the following?

Recent or current soft contact lens wear OR Recent or current hard or gas

permeable contact lens wear

and Do you feel that your patient's problem is contact lens related? Not

sure

THEN:

THE PROBLEM IS CL RELATED

and THE PROBLEM IS NOT CL RELATED

NOTE:

The purpose of this and some following rules is to determine whether the

patient's condition is related to the wearing of contact lenses. The effect of

Appendix C-44
these rules is to create a major branch point in the questioning strategy. If

the corpsman inputs that the problem is CL related, the physical examination

questions will be directed toward a contact lens diagnoses. If the corpsman feels that the problem is not CL related, the PE questions will be directed to

a non-CL diagnoses. If the corpsman is not sure, the program will examine

both possibilities. In any case, these rules prevent the program from considering a CL related diagnosis if the patient is not a CL wearer.

RULE NUMBER: 30

IF:

Does your patient have an ocular history of any of the following?

NOT Recent or current soft contact lens wear

OR Recent or current hard or gas permeable contact lens wear

THEN:

THE PROBLEM IS NOT CL RELATED

NOTE:

The purpose of this and some following rules is to determine whether the

patient's condition is related to the wearing of contact lenses. The effect of

these rules is to create a major branch point in the questioning strategy. If

the corpsman inputs that the problem is CL related, the physical examination

questions will be directed toward a contact lens diagnoses. If the corpsman feels that the problem is not CL related, the PE questions will be directed to

a non-CL diagnoses. If the corpsman is not sure, the program will examine

both possibilities. In any case, these rules prevent the program from considering a CL related diagnosis if the patient is not a CL wearer.

RULE NUMBER: 31

IF:

THE PROBLEM IS CL RELATED

and Has your patient changed any of his ""contact lens care solutionsA"

to new brands in the past month? Yes

THEN:

""*Contact lens solution allergy"" - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

Appendix C-45
corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the patient has recently changes his contact lens care

regimen. A recent change in the care products, is mildly suggestive that a

solution allergy is possible. So, if this rule fires, (+10) is incremented to the

CL soln allergy register.

RULE NUMBER: 32

IF:

THE PROBLEM IS CL RELATED

and Is your patient using any contact lens care solutions

with ""preservatives""? Yes

THEN:

""^Contact lens solution allergy"" - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the patient is using preserved contact lens care solutions.

The use of preserved care products, is mildly suggestive that a solution allergy is possible. So, if this rule fires, (+10) is incremented to the CL soln allergy register.

RULE NUMBER: 33

IF:

THE PROBLEM IS CL RELATED

and Is your patient using any contact lens care solutions with ""preservatives"A? No

THEN:

""AContact lens solution allergy"" - Confidence=-30

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the patient is NOT using preserved contact lens care solutions. If the patient is not using preserved care products, the diagnosis of CL

solution allergy can be virtually ruled out, so (-30) is decremented from the

CL soln allergy register.

Appendix C-46
RULE NUMBER: 34

IF:

Does your patient have a significant medical history of any of the following

conditions? Allergies (hay fever, etc.)

THEN:

""^Allergic conjunctivitis"" - Confidence=1 0

NOTE:

History of allergies is mildly suggestive of allergic conjunctivitis, so presence

of this finding increments the allergic conjunctivitis register (+10) and has no

effect on any other condition.

RULE NUMBER: 35

IF:

Does your patient have a significant medical history of any of the following

conditions? Genital or Labial Herpes

THEN:

""^Herpes simplex keratitis"" - Confidence=1 0

NOTE:

History of generalized herpes infection is mildly indicative that the current

eye disorder may be herpetic in nature. If this finding is positive the herpes

keratitis register is incremented (+10).

RULE NUMBER: 36

IF:

Does your patient have a significant medical history of any of the following

conditions? Connective tissue disorder (arthritis, etc.)

THEN:

""^Chronic idtis"" - Confidence=1 0 and ""Acute iritis"" - Confidence=-1 0

NOTE:

The presence of a systemic condition which predisposes the patient to

chronic iritis is about the only factor the program can use to distinguish beAppendix C-47
tween acute and chronic iritis. Thus, the chronic iritis register is incremented

+10 and the acute iritis register is decremented -10 if the patient has a history of connective tissue disorder.

RULE NUMBER: 37

IF:

Does your patient have a significant medical history of any of the following

conditions? Recent or current URI

THEN:

""^Viral conjunctivitis"" - Confidence=1 0

NOTE:

A history of URI is often associated with viral conjunctivitis so the viral conjunctivitis register is incremented +10 if this finding is positive.

RULE NUMBER: 38

IF:

[VA OD] < 25

THEN:

OD VISION

ELSE:

OD

IS NORMAL

VISION IS REDUCED

RULE NUMBER: 39

IF:

[VA OS] < 25

THEN:

OS VISION

ELSE:

OS VISION

IS NORMAL

IS REDUCED

Appendix C-48
RULE NUMBER: 40

IF:

The pupillary size and response to light appear to be: Normal, both eyes

THEN:

""^Acute angle closure glaucoma"" - Confidence=-30

and ""Acute iritis"" - Confidence=-20

and ""Traumatic iritis"" - Confidence=-20

and ""Chronic iritis"" - Confidence=-20

NOTE:

If the pupils are normal, glaucoma and iritis are less likely. If this rule fires,

angle closure glaucoma is decremented (-30) and the iritis registers are each

decremented (-20). Iritis is decremented less if the corpsman inputs that the

pupils are normal because pupillary changes with iritis are more subtle than

with glaucoma. Normal pupils essentially rule out angle closure, while abnormalities present with iritis may simply go undetected.

RULE NUMBER: 41

IF:

The pupillary size and response to light appear to be: Abnormal, right eye

and The pupillary response to light of the right eye is: Sluggish

and The condition is affecting: NOT Only the left eye

THEN:

""^Traumatic iritisAA - Confidence=20

and ""Acute iritis"" - Confidence=20

and ""Chronic iritis"" - Confidence=20

and ""Acute angle closure glaucoma"" - Confidence=-20

NOTE:

The purpose of this rule is to help diagnose iritis. This rule only fires if the

corpsman inputs that the right pupil is abnormal and its response to light is

abnormal and that the patient's condition is affecting only the right eye or

both eyes. If the condition is affecting only the left eye, but the right pupillary

response is abnormal, which is conflicting information, the rule does not fire.

If the rule does fire, the iritis registers are incremented (+20). A sluggish

pupil in the affected eye contradicts glaucoma so its register is decremented

(-20) if this rule fires.

Appendix C-49
RULE NUMBER: 42

IF:

The pupillary size and response to light appear to be: Abnormal, lefteye

and The pupillary response to light of the left eye is: Sluggish

and The condition is affecting: NOT Only the right eye

THEN:

""^Traumatic iritis"" - Confidence=20

and ""Acute iritis"" - Confidence=20

and ""Chronic iritis"" - Confidence=20

and ""Acute angle closure glaucoma"" - Confidence=-20

NOTE:

The purpose of this rule is to help diagnose iritis. This rule only fires if the

corpsman inputs that the left pupil is abnormal and its response to light is abnormal and that the patient's condition is affecting only the left eye or both

eyes. If the condition is affecting only the right eye, but the left pupillary

response is abnormal, which is conflicting information, the rule does not fire.

If the rule does fire, the iritis registers are incremented (+20). A sluggish

pupil in the affected eye contradicts glaucoma so its register is decremented

(-20) if this rule is true.

RULE NUMBER: 43

IF:

The pupillary size and response to light appear to be: Abnormal, righteye

and The size of the right pupil is (as compared to the left): Constricted

and The condition is affecting: NOT Only the left eye

THEN:

""^Traumatic iritis"" - Confidence=20

and ""Acute iritis"" - Confidence=20

and ""Chronic iritis"" - Confidence=20

and ""Acute angle closure glaucoma"" - Confidence=-20

NOTE:

The purpose of this and the next rule is to help diagnose iritis. Only one of

the two rules will fire. This rule only fires if the corpsman inputs that the right

pupil is abnormal and its size is constricted relative to the left and that the

patient's condition is affecting only the right eye or both eyes. If the condiAppendix C-50
tion is affecting only the left eye, but the right pupil size is constricted, which

is conflicting information, the rule does not fire. If the rule does fire, the iritis

registers are incremented (+20). An abnormal constricted right pupil contradicts angle closure glaucoma so its register is decremented (-20) if this

rule fires.

RULE NUMBER: 44

IF:

The pupillary size and response to light appear to be: Abnormal, left eye

and The size of the left pupil is (as compared to the right): Constricted

and The condition is affecting: NOT Only the right eye

THEN:

""^Traumatic iritis"" - Confidence=20

and ""Acute iritis"" - Confidence=20

and ""Chronic iritis"" - Confidence=20

and ""Acute angle closure glaucoma"" - Confidence=-20

NOTE:

The purpose of this and the previous rule is to help diagnose iritis. Only one

of the two rules will fire. This rule only fires if the corpsman inputs that the

left pupil is abnormal and its size is constricted relative to the right and that

the patient's condition is affecting only the left eye or both eyes. If the condition is affecting only the right eye, but the left pupil size is constricted, which

is conflicting information, the rule does not fire. If the rule does fire, the iritis

registers are incremented (+20). An abnormal constricted left pupil contradicts glaucoma so its register is decremented (-20) if this rule is true.

RULE NUMBER: 45

IF:

The pupillary size and response to light appear to be: Abnormal, right eye

and The pupillary response to light of the right eye is: Absent

and The condition is affecting: NOT Only the left eye

THEN:

""AAcute angle closure glaucoma"" - Confidence=30

NOTE:

The purpose of this rule is to help diagnose glaucoma. This rule only fires if

Appendix C-51
the corpsman inputs that the right pupil is abnormal and its response to light

is absent and that the patient's condition is affecting only the right eye or

both eyes. If the condition is affecting only the left eye, but the right pupillary

response is absent, which is conflicting information, the rule does not fire. If

the rule does fire, the glaucoma register is incremented (+20).

RULE NUMBER: 46

IF:

The pupillary size and response to light appear to be: Abnormal, left eye

and The pupillary response to light of the left eye is: Absent

and The condition is affecting: NOT Only the right eye

THEN:

""^Acute angle closure glaucoma"" - Confidence=30

NOTE:

The purpose of this rule is to help diagnose glaucoma. This rule only fires if

the corpsman inputs that the left pupil is abnormal and its response to light is

absent and that the patient's condition is affecting only the left eye or both

eyes. If the condition is affecting only the right eye, but the left pupillary

response is absent, which is conflicting information, the rule does not fire. If

the rule does fire, the glaucoma register is incremented (+30).

RULE NUMBER: 47

IF:

The pupillary size and response to light appear to be: Abnormal, right eye

and The size of the right pupil is (as compared to the left): Dilated

and The condition is affecting: NOT Only the left eye

THEN:

""^Acute angle closure glaucoma"A"- Confidence=20

and ""Traumatic iritis"" - Confidence=-20

and ""Acute iritis"" - Confidence=-20

and ""Chronic iritis"" - Confidence=-20

NOTE:

The purpose of this and the next rule is to help diagnose glaucoma. Only

one of the two rules will fire. This rule only fires if the corpsman inputs that

the right pupil is abnormal and its size is dilated relative to the left and that

Appendix C-52
the patient's condition is affecting only the right eye or both eyes. If the condition is affecting only the left eye, but the right pupil size is dilated, which is

conflicting information, the rule does not fire. If the rule does fire, the

glaucoma register is incremented (+20). A dilated right pupil in the affected

eye contradicts iritis, so their registers are decremented (-20) if this rule fires.

RULE NUMBER: 48

IF:

The pupillary size and response to light appear to be: Abnormal, left eye

and The pupillary response to light of the left eye is: Absent

and The condition is affecting: NOT Only the right eye

THEN:

""^Acute angle closure glaucoma"" - Confidence=20

and ""Traumatic iritis"" - Confidence=-20

and ""Chronic iritis"" - Confidence=-20

and ""Acute iritis"" - Confidence=-20

NOTE:

The purpose of this and the previous rule is to help diagnose glaucoma.

Only one of the two rules will fire. This rule only fires if the corpsman inputs

that the left pupil is abnormal and its size is dilated relative to the right and

that the patient's condition is affecting only the left eye or both eyes. If the

condition is affecting only the right eye, but the left pupil size is dilated, which

is conflicting information, the rule does not fire. If the rule does fire, the

glaucoma register is incremented (+20). A dilated pupil in the affected eye

contradicts iritis so their registers are decremented (-20) if this rule fires.

RULE NUMBER: 49

IF:

THE PROBLEM IS NOT CL RELATED and The patient's lids appear to

be Normal

THEN:

""^Blepharitis"" - Confidence=-30 and ""Chalazion"" - Confidence=-30

and ""Hordeolum"" - Confidence=-30

NOTE:

If the lids are normal, diseases that primarily affect the lids can be virtually

Appendix C-53
ruled out. Thus, if this rule fires, the blepharitis, chalazion, and hordeolum

registers are decremented (-30).

RULE NUMBER: 50

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? ""Eczematous^" flaking of lid skin

THEN:

""^Blepharitis"" - Confidence=50

NOTE:

Flaking of the skin along the lash line is essentially pathognomonic for

Blepharitis. Thus a positive finding for this sign increments the Blepharitis

register (+50).

RULE NUMBER: 51

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? ""Indurated"" (hard or firm) mass

and The mass is ""Tender""

THEN:

""AHordeolum"" - Confidence=50

and ""Chalazion"" - Confidence=-30

NOTE:

A tender, swollen, red mass in the eyelid is essentially pathognomonic for

hordeola (within the diagnostic domain of this program). Thus, a positive

finding of a hard lid mass which is tender causes a (+50) increment to the

hordeolum register and a (-30) decrement to the chalazion register.

Appendix C-54
RULE NUMBER: 52

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? ""Indurated"" (hard or firm) mass

and The mass is "ANon-tender""

THEN:

""^Chalazion"" - Confidence=50 and ""Hordeolum"" - Confidence=-30

NOTE:

A non-tender mass without inflammation in the eyelid is essentially pathognomonic for chalazia (within the diagnostic domain of this program). Thus, a

positive finding of a hard lid mass which is non-tender causes a (+50) increment to the chalazion register and a (-30) decrement to the hordeolum

register.

RULE NUMBER: 53

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? NOT ""Indurated"" (hard or firm) mass

THEN:

""^Chalazion"A - Confidence=-30 and ""Hordeolum"" - Confidence=-30

NOTE:

The absence of a mass in an otherwise abnormal eyelid indicates that hordeola and chalazia are unlikely diagnoses. Thus, their registers are decremented (-30) if this rule fires.

RULE NUMBER: 54

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

Appendix C-55
and Are any of the following abnormalities present in your patient's lids

and lashes? ^^Erythema""

THEN:

""*Chalazion"" - Confidence=-1 0

and ""Hordeolum"" - Confidence=10

and ""BlepharitisA" - Confidence=10

NOTE:

Among the lid diseases, redness is likely with hordeola and blepharitis but

not chalazia. If this rule is true, the reristers of these diseases are incremented (+10) (+10) and (-10) respectively.

RULE NUMBER: 55

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? ""Edema"A

THEN:

""AAllergic conjunctivitis"" - Confidence= 10

and ""HordeolumA" - Confidence=10

and ""BlepharitisA" - Confidence=1 0

NOTE:

If the lids are edematous, the registers of allergic conjunctivitis, blepharitis

and hordeolum are all incremented (+10) by this rule.

RULE NUMBER: 56

IF:

THE PROBLEM IS NOT CL RELATED

and The patient's lids appear to be Abnormal

and Are any of the following abnormalities present in your patient's lids

and lashes? Crusted material on lash line

Appendix C-56
THEN:

""^Bacterial conjunctivitis"" - Confidence=1 0

and ""Viral conjunctivitisA" - Confidence=1 0

and ""Blephadtis"" - Confidence=10

NOTE:

The presence of crusting along the lid margin is indicative of a conjunctival

or lid infection. Thus, if this sign is present, this rule will increment (+10) to

the registers of viral and bacterial conjunctivitis and blepharitis.

RULE NUMBER: 57

IF:

The ""conjunctiva"" appears to be Normal

THEN:

""^Bacterial conjunctivitis"" - Confidence=-50

and ""Viral conjunctivitisA" - Confidence=-50

and ""Allergic conjunctivitis"" - Confidence=-50

and ""Pneumococcal corneal ulcer"A - Confidence=-20

and ""Pseudomonas comeal ulcer"A - Confidence=-20

and ""Herpes simplex keratitisA" - Confidence=-20

and ""Traumatic iritisA" - Confidence=-20

and ""Acute iritis"" - Confidence=-20

and ""Chronic iritis"" - Confidence=-1 0

and ""Corneal abrasion"" - Confidence=-1 0

and ""Acute angle closure glaucoma"" - Confidence=-20

and ""Subconjunctival hemorrhage"" - Confidence=-50

NOTE:

If the conjunctiva is normal, conjunctivitis is virtually ruled-out, thus each conjunctividity is decremented (-50) if this rule is true. To a lesser extent, corneal ulcers can be decremented (-20) and comeal abrasions can be

decremented slightly (-10). Iritis and glaucoma usually cause some conjunctival injection so their registers are decremented also when this rule fires.

RULE NUMBER: 58

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present?

Appendix C-57
""^Redness""

and The location of the conjunctival injection can best be described as:

""^Circumcorneal""

THEN:

""^Traumatic iritis"" - Confidence=20

and ""Acute iritis"" - Confidence=20

and ""Chronic iritis"" - Confidence=20

and ""Acute angle closure glaucoma"" - Confidence=20

NOTE:

Circumcorneal injection is common in conditions such as iritis and acute

glaucoma. However, this sign is of no value in differentiating between these

conditions. Thus, if this rule is true, the iritis and glaucoma registers are all

incremented (+20).

RULE NUMBER: 59

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Redness""

and The location of the conjunctival injection can best be described as:

""^Diffuse""

THEN:

""^Viral conjunctivitis"" - Confidence=20

and ""Allergic conjunctivitis"" - Confidence=20

and ""Bacterial conjunctivitis"" - Confidence=20

NOTE:

Diffuse conjunctival injection is indicative of conjunctivitis of any etiology. Although other conditions such as corneal abrasion and ulcer will often

produce diffuse injection, the firing of this rule does not affect their registers

as other findings are more important for their diagnoses.

RULE NUMBER: 60

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present?

Appendix C-58
""^Redness""

and The location of the conjunctival injection can best be described as:

""^Sectorial""

THEN:

""^Subconjunctival hemorrhage"" - Confidence=30

NOTE:

Sectorial injection is generally indicative of a subconjunctival hemorrhage,

thus, its register is incremented (+30) if this finding is positive. This rule has

no effect on other disease registers because sectorial injection without

regard to severity may or may not occur with virtually all of the diseases considered.

RULE NUMBER: 61

IF:

The "^conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Redness""

and How would you rate the degree of the ""conjunctival redness""?

Severe

THEN:

""^Subconjunctival hemorrhage"" - Confidence=30

and ""Allergic conjunctivitis"" - Confidence=-1 0

NOTE:

Severe conjunctival injection can occur with almost all of the disorders causing conjunctival injection. In the initial and early subsequent presentation of

subconjunctival hemorrhage, redness will always be severe. When this rule

fires, the subconjunctival hemorrhage register is incremented (+30). It is unlikely that allergic conjunctivitis would produce severe bulbar injection so its

register is decremented (-10) if this rule is true.

RULE NUMBER: 62

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Redness""

Appendix C-59
and How would you rate the degree of the ""conjunctival redness""?

Moderate

THEN:

""^Subconjunctival hemorrhage"" - Confidence=-1 0

NOTE:

Moderate conjunctival injection can occur with almost all of the disorders

causing conjunctival injection. In the initial and early subsequent presentation of subconjunctival hemorrhage, when this program is likely to be consulted, redness will always be severe--not moderate. When this rule fires,

the subconjunctival hemorrhage register is decremented (-10). The firing of

this rule has no effect on other disease registers.

RULE NUMBER: 63

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Redness""

and How would you rate the degree of the ""conjunctival redness"A?

Mild

THEN:

"^^Subconjunctival hemorrhage"A"- Confidence=-30

NOTE:

Mild conjunctival injection can occur with almost all of the disorders causing

conjunctival injection. In the initial and early subsequent presentation of subconjunctival hemorrhage, when this program is likely to be consulted, redness will always be severe--not mild. When this rule fires, the

subconjunctival hemorrhage register is decremented (-30). The firing of this

rule has no effect on other disease registers.

RULE NUMBER: 64

IF:

The A"conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""AFollicles""

Appendix C-60
THEN:

""^Viral conjunctivitis"" - Confidence=30

and ""Allergic conjunctivitis"" - Confidence=-1 0

and ""Bacterial conjunctivitis"" - Confidence=- 10

NOTE:

Follicles (usually found in the inferior fornix conjunctiva) are fairly indicative

of a viral infection. They are usually not present in bacterial (exception:

chlamydia) or allergic conjunctivitis. It is unlikely that the corpsman will

detect follicles unless they are severe so it is unlikely this rule will ever fire. If

it does fire, the Viral conjunctivitis register is incremented (+30) and the bacterial and allergic conjunctivitis registers are decremented (-10).

RULE NUMBER: 65

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Papillae""

THEN:

""^Allergic conjunctivitis"" - Confidence=20

NOTE:

Papillary hypertrophy is associated with vernal conjunctivitis as well as CLIGPC. The effect of this rule if true is to increment the allergic conjunctivitis

register (+20). GPC is considered in a later contact lens specific rule.

RULE NUMBER: 66

IF:

The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival abnormalities present? ""^Edema""

THEN:

""^Allergic conjunctivitis"" - Confidence=20

and ""Viral conjunctivitis"" - Confidence=10

NOTE:

Chemosis is generally an allergic phenomenon, thus the allergic

Appendix C-61
conjunctivitis register is incremented (+20) if this rule fires. Chemosis can

also be present in viral conditions, but generally this is a less likely cause of

corpsman-detectable chemosis, so the viral conjunctivitis register is incremented (+10) if chemosis is present.

RULE NUMBER: 67

IF:

Does your patient complain of any of these other ocular symptoms?

Discharge (other than tearing) OR Excessive tearing OR Lids stuck

together upon arising

or: The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival discharges present? ""AExcessive tearing""

THEN:

"^^Pneumococcal corneal ulcer"" - Confidence=1 0

and ""Pseudomonas corneal ulcer"" - Confidence=1 0

and ""Herpes simplex keratitis"" - Confidence=1 0

and ^^Corneal abrasion"" - Confidence=10

and ""Traumatic iritis"" - Confidence=10

and ""Acute iritis"" - Confidence=10

and ""Chronic iritis"" - Confidence=1 0

and ""Acute angle closure glaucoma"" - Confidence=10

and ""Viral conjunctivitis"" - Confidence=10

and ""Allergic conjunctivitis"" - Confidence=10

NOTE:

Like photophobia, which is often the cause of excessive tearing, this

symptom can occur variably with many of the diseases the program considers. Thus, all conditions which affect the cornea and iris are incremented

(+10) if excessive tearing is present. Also, viral and allergic conjunctivitis are

incremented (+10) as this symptom often is present in this symptom. This

rule also forces the corpsman to look for conjunctival discharge if either the

conjunctiva is abnormal on exam or the patient c/do discharge in the history.

RULE NUMBER: 68

IF:

Does your patient complain of any of these other ocular symptoms?

Discharge (other than tearing) OR Excessive tearing OR Lids stuck

Appendix C-62
together upon arising

or: The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival discharges present? ""^Stringy""

THEN:

""^Allergic conjunctivitis"" - Confidence=20

NOTE:

A white or clear stingy discharge is present in some severe cases of allergic

conjunctivitis (i.e. vernal conjunctivitis). It is unlikely this symptom will be

present in most allergic conjunctividities but if it is, the allergic conjunctivitis

register will be incremented (+20).

RULE NUMBER: 69

IF:

Does your patient complain of any of these other ocular symptoms?

Discharge (other than tearing) OR Excessive tearing OR Lids stuck

together upon arising

or: The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival discharges present? ""^Mucoid""

THEN:

""AViral conjunctivitis"" - Confidence=20

NOTE:

A purely mucoid discharge may be present in viral conjunctivitis. If this rule

fires, the viral conjunctivitis register will be incremented (+20).

RULE NUMBER: 70

IF:

Does your patient complain of any of these other ocular symptoms?

Discharge (other than tearing) OR Excessive tearing OR Lids stuck

together upon arising

or: The ""conjunctiva"" appears to be Abnormal

and Are any of the following conjunctival discharges present? "^^Mucopurulent""

Appendix C-63

RULE NUMBER: 72

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes

and Did the conjunctival smear reveal abnormal amounts of any of the

following cell types? AANeutrophilsAA

THEN:

AABacterial conjunctivitisAA - Confidence=30

and AAPneumococcal corneal ulcer^^ - Confidence=20

and AAPseudomonas comeal ulcer^^ - Confidence=20

NOTE:

The presence of more than a few random neutrophils in a conjunctival smear

usually is indicative of a bacterial infection. Thus, if this rule fires, the bacterial conjunctivitis register is incremented (+30). Also, the registers of the

two bacterial corneal ulcers are incremented (+20). Their registers will be affected more by later rules dealing with corneal integrity.

RULE NUMBER: 73

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes

and Did the conjunctival smear reveal abnormal amounts of any of the

following cell types? AAEosinophilsAA

THEN:

AAAllergic conjunctivitisAA - Confidence=30

NOTE:

Eosinophils are almost always associated with an allergic condition, thus, if

this rule fires, the allergic conjunctivitis register is incremented (+30). This

rule has no effect on any other register and, because no else clause is used,

it has no effect an any register if it is not true.

Appendix C-65
RULE NUMBER: 74

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes

and Did the conjunctival smear reveal abnormal amounts of any of the

following cell types? AALymphocytesAA OR AAMonocytesAA

THEN:

AAViral conjunctivitisAA - Confidence=30

and AAHerpes simplex keratitisAA - Confidence=30

NOTE:

The presence of mononuclear cells (lymphocytes and monocytes) is indicative of a viral infection. Thus the registers of viral conjunctivitis and Herpes simplex keratitis are both incremented (+30) if mononuclear cells are

present. If this rule is not true, it has no effect on any disease register.

RULE NUMBER: 75

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes

and Did the conjunctival smear reveal abnormal amounts of any of the

following cell types? Bacteria

THEN:

AABacterial conjunctivitisAA - Confidence=30

NOTE:

If bacteria (without regard to type) are present in the conjunctival smear, the

bacterial conjunctivitis register is incremented (+30). Bacterial corneal ulcers

will be dealt with in later rules which differentiate types of bacteria or call for

comeal smears. If bacteria is not present, this rule does not fire and has no

effect on any disease register.

Appendix C-66
RULE NUMBER: 76

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes and

Did the conjunctival smear reveal abnormal amounts of any of the following cell types? Bacteria

and What type(s) of bacteria were present? Gram-positive cocci

THEN:

AAPneumococcal corneal ulcerAA - Confidence=20

NOTE:

This rule helps to differentiate between pseudomonal and pneumococcal corneal ulcer. If G+ cocci are present in the conjunctival smear, it is suggestive

that pneumococcus (among other pathogens) might be present. Thus, if this

rule fires the pneumococcus register is incremented (+20). The comeal ulcers will be dealt with more fully in later rules regarding the cornea specifically.

RULE NUMBER: 77

IF:

THE PROBLEM IS NOT CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Were you able to obtain a conjunctival smear? Yes

and Did the conjunctival smear reveal abnormal amounts of any of the following cell types? Bacteria

and What type(s) of bacteria were present? Gram-negative rods

THEN:

AAPseudomonas corneal ulcerAA - Confidence=20

NOTE:

This rule helps to differentiate between pseudomonal and pneumococcal corneal ulcer. If G- rods are present in the conjunctival smear, it is suggestive

that pseudomonas (among other pathogens) might be present. Thus, if this

rule fires the pseudomonas register is incremented (+20). The comeal ulcers will be dealt with more fully in later rules regarding the cornea specificalAppendix C-67
ly. Gram negative cocci is not used in the present program but will be if hyperacute conjunctivitis is added to the disease list.

RULE NUMBER: 78

IF:

THE PROBLEM IS NOT CL RELATED

and What did your examination of the AApre-auricular nodesAA Reveal?

AAPalpable and non-tenderAA

THEN:

AAViral conjunctivitisAA - Confidence=1 0

and AABacterial conjunctivitisAA - Confidence=-10

NOTE:

Swollen non tender PA nodes are usually indicative of a viral infection. This

sign, if present is a good indicator so the viral conjunctivitis register is incremented (+10) if this rule fires. Because bacterial conjunctivitis would generally not cause PA node enlargement, its register is decremented (-10). The

absence of this sign is not indicative of anything so there is no else component to this rule.

RULE NUMBER: 79

IF:

THE PROBLEM IS NOT CL RELATED

and What did your examination of the AApre-auricular nodesAA Reveal?

AAPalpable and tenderAA

THEN:

AAViral conjunctivitisAA - Confidence=10

and AABacterial conjunctivitisAA - Confidence=-1 0

and AAHerpes simplex keratitisAA - Confidence=10

NOTE:

Swollen tender PA nodes are usually indicative of a viral infection. This sign,

if present is a good indicator so the viral conjunctivitis and Herpes keratitis

registers are incremented (+10) if this rule fires. Because bacterial conjunctivitis would generally not cause PA node enlargement, its register is

decremented (-10). The absence of this sign is not indicative of anything so

there is no else component to this rule.

Appendix C-68
RULE NUMBER: 80

IF:

The AAconjunctivaAA appears to be Normal

THEN:

Are any of the following conjunctival abnormalities present? None of

the above

NOTE:

The purpose of this rule is to assign a value to the qualifier "Are any of the

following conjunctival abnormalities..." because this qualifier is used in an or

clause of a later rule. Without this rule, it is possible that the program would

ask this qualifier even if the corpsman had previously entered that the conjunctiva is normal.

RULE NUMBER: 81

IF:

The cornea is Abnormal and Are any of the following corneal abnormalities present? AAInfiltratesAA (Gray or white patches)

THEN:

AAPneumococcal corneal ulcerAA - Confidence=30 and AAPseudomonas

corneal ulcerAA - Confidence=30 and AACorneal abrasionAA - Confidence=-30

NOTE:

The presence of a corneal infiltrate is almost pathognomatic for a corneal

ulcer. It's presence also strongly argues against a simple comeal abrasion

which would be in the differential. Thus, the result of this rule's firing is to increment the two ulcer registers (+30) and decrement the corneal abrasion

register (-30).

RULE NUMBER: 82

IF:

The cornea is Abnormal

and Are any of the following corneal abnormalities present? Cloudy or

hazy appearance

Appendix C-69
and Which part of the cornea appears cloudy or hazy? Entire cornea

THEN:

AAAcute angle closure glaucomaAA - Confidence=30

NOTE:

If the cornea appears cloudy or steamy overall, generallized corneal edema

is probably the cause. The only disease considered by this program which

could cause this appearance is AACG. Thus, if this sign is present, the

AACG register is incremented (+30).

RULE NUMBER: 83 IF:

The cornea is Abnormal

and Are any of the following corneal abnormalities present? Cloudy or

hazy appearance

and Which part of the cornea appears cloudy or hazy? Superior one-third

and THE PROBLEM IS CL RELATED

THEN:

Contact lens induced AASuperior limbic conjunctivitisAA - Confidence=30

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the cornea is coudy or hazy in the superior quadrant. If this

rule fires, the register for CLI-SLK is incremented (+30). The order of

qualifiers in this rule is designed to force the question of location of corneal

clouding whether the condition is contact lens related or not if the corpsman

has input the cornea is abnormal and cloudy.

RULE NUMBER: 84

IF:

The cornea is Abnormal

and Are any of the following corneal abnormalities present? Scratch or

abrasion

and Which of the following choices best describes the appearance of the

abraded area? Clean and sterile

Appendix C-70
THEN:

AAPneumococcal comeal ulcerAA - Confidence=-1 0

and AAPseudomonas corneal ulcerAA - Confidence=- 10

and AACorneal abrasionAA - Confidence=10

NOTE:

If the abraded area is sterile, corneal ulcer is somewhat unlikely. Thus, the

two ulcer registers are decremented (-10) and the corneal abrasion register

is incremented (+10) if the abrasion site is clean and sterile.

RULE NUMBER: 85

IF:

The cornea is Abnormal

and Are any of the following corneal abnormalities present? Scratch or

abrasion

and Which of the following choices best describes the appearance of the

abraded area? Adherant greenish AAdischargeAA or AAexudateAA OR Adherant white discharge or exudate

and Were you able to obtain a AAGram's stainAA of the AAexudateAA from

the site of comeal involvement? Yes

and What were the results of the AAGram's stainAA of the corneal AAexudateAA? G+ Cocci

THEN:

AAPneumococcal comeal ulcerAA - Confidence=20

and AAPseudomonas comeal ulcerAA - Confidence=-20

and AACorneal abrasionAA - Confidence=-50

NOTE:

If an abraded site contains G+ cocci, the only possible disease considered

by this program is Pneumococcal corneal ulcer. Thus, its register is incremented +20 while the registers for Pseudomonas and corneal abrasion are

decremented (-20) and (-50) respectively as they would frequently be in the

differential.

RULE NUMBER: 86

IF:

The cornea is Abnormal

Appendix C-71
and Are any of the following comeal abnormalities present? Scratch or

abrasion

and Which of the following choices best describes the appearance of the

abraded area? Adherant greenish AAdischargeAA or AAexudateAA OR

Adherant white discharge or exudate

and Were you able to obtain a AAGram's stainAA of the AAexudateAA from

the site of corneal involvement? Yes

and What were the results of the AAGram's stainAA of the corneal

AAexudateAA? G- Rods

THEN:

AAPseudomonas corneal ulcerAA - Confidence=20

and AAPneumococcal corneal ulcerAA - Confidence=-20

and AACorneal abrasionAA - Confidence=-50

NOTE:

If an abraded site contains G- rods, the only possible disease considered by

this program is Pseudomonal corneal ulcer. Thus, its register is incremented

+50 while the registers for Pneumococcas and corneal abrasion are decremented (-20) and (-50) respectively as they would frequently be in the differential.

RULE NUMBER: 87

IF:

The cornea is Abnormal

and Are any of the following corneal abnormalities present? Foreign

body present

THEN:

AAComeal foreign bodyAA - Confidence=50

NOTE:

This diagnosis of corneal foreign body is fairly straight forward if a foreign

body is present on the cornea. Thus, if true, this rule increments the corneal

foreign body rule (+50).

Appendix C-72

RULE NUMBER: 88 IF:

The cornea is Abnormal
and Are any of the following comeal abnormalities present? Scratch or

abrasion

and Which of the following choices best describes the appearance of the

abraded area? Adherant greenish AAdischargeAA or AAexudateAA

THEN:

AAPseudomonas corneal ulcerAA - Confidence=20

and AAPneumococcal corneal ulcerAA - Confidence=-20

and AAHerpes simplex keratitisAA - Confidence=-20

and AACorneal abrasionAA - Confidence=-20

NOTE:

A greenish purulent discharge from an ulcer site is virtually pathognomonic

for Pseudomonas. Thus, if this sign is present, its register is incremented

(+20). The presence of a greenish exudate contradicts Pneumococcal ulcer,

corneal abraision and herpes, so their registers are decremented (-20) if this

rule fires.

RULE NUMBER: 89

IF:

The cornea is Abnormal

and Are any of the following comeal abnormalities present? Scratch or

abrasion

and Which of the following choices best describes the appearance of the

abraded area? Adherant white discharge or exudate

THEN:

AAPneumococcal corneal ulcerAA - Confidence=20

and AAPseudomonas corneal ulcerAA - Confidence=20

and AAHerpes simplex keratitisAA - Confidence=-20

and AACorneal abrasionAA - Confidence=-20

NOTE:

If a purulent discharge is present in an abrasion site, the abrasion is ulcerated. Both pseudomonas and pneumococcus can produce a white discharge so both of their registers are incremented (+20) if a discharge is

present. If a white discharge is present, comeal abrasion and herpes are

decremented (-20).

Appendix C-73
RULE NUMBER: 90

IF:

Does your patient complain of any of the following symptoms of ocular

AAirritationAA? Scratchy or foreign body sensation OR Pain OR Burning

OR AAPhotophobiaAA

or: The AAconjunctivaAA appears to be Abnormal

or: The cornea is Abnormal

THEN:

FLUORESCEIN STAINING SHOULD BE DONE

ELSE:

FLUORESCEIN STAINING SHOULD NOT BE DONE

NOTE:

The purpose of this rule is to determine whether questions about fluorescien

staining should be asked. The qualifier in the THEN section of this rule is

asked in the IF section of later rules. The second qualifier in the else part of

the rule is included because it is asked as part of an or block in a later rule.

RULE NUMBER: 91

IF:

FLUORESCEIN STAINING SHOULD NOT BE DONE

THEN:

Does the cornea exhibit AAfluorescein stainingAA? No

and Does the staining pattern match either of these patterns? None of the

above

NOTE:

This rule exists because the qualifiers in the then part are used in an or block

in later rules.

RULE NUMBER: 92

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? No

Appendix C-74
and The cornea is Normal

THEN:

AAPneumococcal corneal ulcerAA - Confidence=-50

and AAPseudomonas corneal ulcerAA - Confidence=-50

and AAHerpes simplex keratitisAA - Confidence=-50

and AACorneal abrasionAA - Confidence=-50

NOTE:

If no corneal staining is present and the cornea is reported normal, the corneal epithelium is intact. The corneal diseases listed in the then section of

this rule can be virtually ruled out if the epithelium is intact. Thus, each of

their registers are decremented (-50) if no corneal staining is present. The

rule is also designed to fire the corneal staining question if the conjunctiva is

abnormal even if the corpsman reports that the cornea is normal.

RULE NUMBER: 93 IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? Yes

and Does the staining pattern match either of these patterns? AADendriticAA (branching)

THEN:

AAHerpes simplex keratitisAA - Confidence=50

and AAPneumococcal corneal ulcerAA - Confidence=-20

and AAPseudomonas corneal ulcerAA - Confidence=-20

and AACorneal abrasionAA - Confidence=-20

NOTE:

This rule increments herpes (+50) if dendritic staining is present as this is

pathognomonic for herpes. Other corneal conditions are decremented (-20).

FB is not decremented because a FB tracking stain could be confused for a

dendritic stain by an inexperienced observer.

RULE NUMBER: 94 IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? Yes

and Does the staining pattern match either of these pattems? AAForeign

body trackingAA (zig-zag)

Appendix C-75
THEN:

AACorneal foreign bodyAA - Confidence=20

and AAPneumococcal corneal ulcerAA - Confidence=-20

and AAPseudomonas corneal ulcerAA - Confidence=-20

and CONSIDER LID EVERSION YES

ELSE:

CONSIDER LID EVERSION NO

NOTE:

This rule increments FB if a tracking stain is present. Pseudo and pneumo

are decremented (-20), but corneal abrasion and herpes are not affected because a corneal abrasion is still present with a FB that causes tracking and

the dendritic pattern of herpes could be mistaken for FB tracking. Consider

lid eversion is included because a later rule (114) needs this information in

an or block.

RULE NUMBER: 95

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit A^fluorescein staining^A? Yes

and Does the staining pattern match either of these patterns? NOT

AADendriticAA (branching)

THEN:

AAHerpes simplex keratitisAA - Confidence=-20

NOTE:

This rule decrements herpes (-20) if dendritic staining is not present. Such

staining does not have to be present to diagnose herpes but is very common.

RULE NUMBER: 96

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit ^^fluorescein stainingA^? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The size of the area(s) of corneal staining can best be described as

Punctate (pinpoint)

Appendix C-76
THEN:

THERE IS PUNCTATE CORNEAL STAINING

ELSE:

THERE IS NO PUNCTATE CORNEAL STAINING

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality,

or if a pathognomonic staining pattern has already been revealed. Second,

these rules conclude in conditions which will be combined in later rules. In

this way, the IF part of the later rules can be less complex as the question

order hierachy will already be established.

RULE NUMBER: 97

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the comea exhibit ^^fluorescein staining^A? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The size of the area(s) of corneal staining can best be described as

Less than 1 mm

THEN:

THE STAINED AREA IS LESS THAN 1 MM

ELSE:

THE STAINED AREA IS NOT LESS THAN 1 MM

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality,

or if a pathognomonic staining pattern has already been revealed. Second,

these rules conclude in conditions which will be combined in later rules. In

this way, the IF part of the later rules can be less complex as the question

order hierachy will already be established.

Appendix C-77
RULE NUMBER: 98

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The size of the area(s) of corneal staining can best be described as

Larger than 1 mm

THEN:

THE AREA OF STAINING IS LARGER THAN 1 MM

ELSE:

THE AREA OF STAINING IS NOT LARGER THAN 1 MM

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality,

or if a pathognomonic staining pattern has already been revealed. Second,

these rules conclude in conditions which will be combined in later rules. In

this way, the IF part of the later rules can be less complex as the question

order hierachy will already be established.

RULE NUMBER: 99

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The amount of corneal staining is best characterized as A single area

THEN:

STAINING IS ONLY IN ONE AREA

ELSE:

STAINING IS NOT ONLY IN ONE AREA

Appendix C-78
NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

RULE NUMBER: 100

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the comea exhibit A^fluorescein staining^^? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The amount of corneal staining is best characterized as 2 to 3 areas

THEN:

THE STAINING IS IN 2-3 AREAS

ELSE:

THE STAINING IS NOT IN 2-3 AREAS

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

RULE NUMBER: 101

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit A^fluorescein staining^A? Yes

and Does the staining pattern match either of these patterns? None of the

above

Appendix C-79
and The amount of corneal staining is best characterized as Multiple

areas

THEN:

THE STAIN AMT IS MULTIPLE AREAS

ELSE:

THE STAIN AMT IS NOT MULTPLE AREAS

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

RULE NUMBER: 102

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The location of the corneal staining is best characterized as: Central

THEN:

STAIN LOCATION IS CENTRAL

ELSE:

STAIN LOCATION IS NOT CENTRAL

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

Appendix C-80
RULE NUMBER: 103

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit ^^fluorescein staining^A? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The location of the corneal staining is best characterized as:

Peripheral

THEN:

THE STAIN LOCATION IS PERIPHERAL

ELSE:

THE STAIN LOCATION IS NOT PERIPHERAL

NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

RULE NUMBER: 104

IF:

FLUORESCEIN STAINING SHOULD BE DONE

and Does the cornea exhibit ^'fluorescein staining^A? Yes

and Does the staining pattern match either of these patterns? None of the

above

and The location of the corneal staining is best characterized as:

AADiffuseAA

THEN:

THE STAIN LOCATION IS DIFFUSE

ELSE:

THE STAIN LOCATION IS NOT DIFFUSE

Appendix C-81
NOTE:

The purpose of this series of rules is two-fold. First, these rules force the program to ask questions about staining in a logical sequence and prevent the

program from asking questions about the nature of the corneal staining if

there is no corneal staining or there is no corneal or conjunctival abnormality.

Second, these rules conclude in conditions which will be combined in later

rules. In this way, the IF part of the later rules can be less complex as the

question order hierachy will already be established.

RULE NUMBER: 105

IF:

THE AREA OF STAINING IS LARGER THAN 1 MM

and THE STAIN AMT IS NOT MULTPLE AREAS

and Are any of the following corneal abnormalities present? AALocalized

edematous areaAA OR AAInfiltratesAA (Gray or white patches)

THEN:

AAPneumococcal corneal ulcerAA - Confidence=20

and AAPseudomonas corneal ulcerAA - Confidence=20

and AACorneal abrasionAA - Confidence=-20

NOTE:

The purpose of this rule is to increment the ulcer registers if staining is in 1-3

areas and corneal edema or infiltrates are present. This combination of

symptoms is fairly indicative of an ulcer vs an abrasion.

RULE NUMBER: 106

IF:

THERE IS PUNCTATE CORNEAL STAINING

and THE STAIN LOCATION IS DIFFUSE

THEN:

AAViral conjunctivitisAA - Confidence=30

NOTE:

Diffuse punctate staining is often present in viral conjunctivitis, especially

that caused by EKC. Thus, when present, the viral conjunctivitis register is

incremented (+30).

Appendix C-82
RULE NUMBER: 107

IF:

THE PROBLEM IS NOT CL RELATED

and The AAanterior chamberAA is: Abnormal

and Are any of the following AAanterior chamberAA abnormalities present?

A/C contains blood

THEN:

AAHyphemaAA - Confidence=50

NOTE:

This rule fires only if the corpsman inputs that the A/C is abnormal and that

the A/C contains blood. Because blood in the A/C is, by definition, a

hyphema, the hyphema register is incremented (+50) to ensure that it is

above display threshold.

RULE NUMBER: 108

IF:

THE PROBLEM IS NOT CL RELATED

and The AAanterior chamberAA is: Abnormal

and Are any of the following AAanterior chamber^^ abnormalities present?

A/C contains pus

THEN:

AAPneumococcal corneal ulcerAA - Confidence=1 0

and AAPseudomonas corneal ulcerAA - Confidence=1 0

NOTE:

This rule fires only if the corpsman inputs that the A/C is abnormal and that

the A/C contains pus. The only diseases that are considered by the program

capable of causing purulence of the A/C are the two ulcerative keratitises.

They are not the only possible causes, however, and the corpsman's ability

to detect A/C purulence is suspect. Thus, if this rule is true, the registers of

those two conditions are incremented (+10).

Appendix C-83
RULE NUMBER: 109

IF:

THE PROBLEM IS NOT CL RELATED

and The AAanterior chamberAA is: Abnormal

and Are any of the following AAanterior chamber`AA abnormalities present? AAAqueus humorAA appears cloudy

THEN:

AATraumatic iritisAA - Confidence=1 0

and AAAcute iritisAA - Confidence=1 0

and AAChronic iritisAA - Confidence=10

NOTE:

This rule fires only if the corpsman inputs that the A/C is abnormal and that

the A/C appears cloudy. The only diseases capable of causing cloudiness of

the NC are the three iritises They are not the only possible causes, however, and the corpsman's ability to detect A/C clouding is suspect. Thus, if

this rule is true, the registers of those two conditions are incremented (+10).

RULE NUMBER: 110

IF:

The AAanterior chamberAA is: Normal

THEN:

AAHyphemaAA - Confidence=-50

NOTE:

If the A/C is normal, hyphema can be virtually ruled out, thus if the corpsman

inputs normal for this qualifier, the hyphema register is decremented (-50)

RULE NUMBER: 111

IF:

Does the cornea exhibit A^fluorescein stainingA^? Ye

or: Does your patient have an ocular history of any of the following?

Previous ocular herpes infections

or: Does your patient have a significant medical history of any of the

following conditions? Genital or Labial Herpes

Appendix C-84
or: What did your examination of the AApre-auricular nodesAA Reveal?

AAPalpable and tenderAA

and THE PROBLEM IS NOT CL RELATED

THEN:

CORNEAL SENSITIVITY SHOULD BE MEASURED

ELSE:

CORNEAL SENSITIVITY SHOULD NOT BE MEASURED

NOTE:

The purpose of this rule is to determine when the corpsman should be asked

to perform a test of corneal sensitivity. When any one of the conditions in

the IF part of the rule is true, this rule fires and subsequent rules about the

corneal sensitivity test will be tested.

RULE NUMBER: 112

IF:

Does your patient complain of any of the following symptoms of AAvisual

disturbanceAA? Blurred or decreased vision OR AAHaloes around

lightsAA

or: Does your patient complain of any of the following symptoms of

ocular ^^irritation^A? Pain

or: Does your patient have an ocular history of any of the following?AAHigh HyperopiaAA (spectacle Rx > +3.OOD)

or: Does your patient have a significant medical history of any of the

following conditions? Connective tissue disorder (arthritis, etc.)

or: The pupillary size and response to light appear to be: NOT Normal,

both eyes

and THE PROBLEM IS NOT CL RELATED

THEN:

lOP SHOULD BE EVALUATED

ELSE:

lOP SHOULD NOT BE EVALUATED

NOTE:

The purpose of this rule is to determine if symptoms suggesting the need for

lOP evaluation are present. If any of the signs or symptoms listed in the if

part of the rule are present, the program will decide it needs an lOP deterAppendix C-85
mination either by tonometer or tactile tensions. A series of later rules are effected by this rule as they test the conclusion of this rule in their premise.

RULE NUMBER: 113

IF:

Does your patient complain of any of the following symptoms of AAvisual

disturbance^A? AADistorted visionAA OR ^AFlashing lightsA^ OR

"^^FloatersAA OR ^AHaloes around lightsAA

or: Is there an ^Aassociated history of ocular traumaAA? Yes

or: Does your patient have an ocular history of any of the following? AAHigh Myopia^A (spectacle Rx <-4.OOD) OR ^AHigh HyperopiaAA

(spectacle Rx > +3.OOD)

or: The AAonsetAA of symptoms can best be described as: Sudden and

THE PROBLEM IS NOT CL RELATED

THEN:

confrontation VF Should be done

ELSE:

confrontation VF Should not be done

NOTE:

The purpose of this rule is to decide if confrontation visual fields should be

performed based on the presence of the symptoms listed in the if part of the

rule. If any one of the symptoms listed is positive, the rule is true and the

corpsman will be asked for visual field findings. If all of the symptoms listed

are negative, the corpsman will not be queried about VF findings. The rule is

currently quite conservative--in most cases the corpsman will be required to

provide VF data.

RULE NUMBER: 114

IF:

THE PROBLEM IS CL RELATED

or: Does your patient complain of any of the following symptoms of

ocular AAirritationAA? Scratchy or foreign body sensation

or: CONSIDER LID EVERSION YES

THEN:

LID EVERSION SHOULD BE PERFORMED

Appendix C-86
ELSE:

LID EVERSION SHOULD NOT BE PERFORMED

NOTE:

The purpose of this rule is to determine if the lid eversion procedure should

be performed. If the patient is a CL wearer or he complains of a scratchy

sensation, or has FB tracking staining (from rule 94), this rule fires and subsequent rules asking about the everted lids are tested.

RULE NUMBER: 115

IF:

lOP SHOULD NOT BE EVALUATED

and confrontation VF Should not be done

and CORNEAL SENSITIVITY SHOULD NOT BE MEASURED

and THE PROBLEM IS NOT CL RELATED

and LID EVERSION SHOULD NOT BE PERFORMED

THEN:

SPTST.SCR SHOULD NOT BE DISPLAYED

and AAAcute angle closure glaucomaAA - Confidence=0

RULE NUMBER: 116

IF:

THE PROBLEM IS CL RELATED

and Does your patient complain of any of the following symptoms of

ocular irritation^^? Itching

THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=10

and Contact lens induced AASuperior limbic conjunctivitisAA -

Confidence=10

and AAContact lens solution allergyAA - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and itching is present. If this rule fires, the registers of the appropriate contact lens disorders are incremented (+10), as this symptom is

only mildly suggestive of any of them.

Appendix C-87
RULE NUMBER: 117

IF:

THE PROBLEM IS CL RELATED

and Does your patient complain of any of the following symptoms of

ocular AAirritationAA? Burning

THEN:

Contact lens induced AASuperior limbic conjunctivitisAA - Confidence=10

and AAContact lens solution allergyAA - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and a burning sensation is present. If this rule fires, the registers for

SLK and solution allergy are incremented only (+10), because the meaning

of the symptom is vague.

RULE NUMBER: 118

IF:

THE PROBLEM IS CL RELATED

and Does your patient complain of any of the following symptoms of

ocular ^^irritation^^? ^^Photophobia^^

THEN:

Contact lens induced AASuperior limbic conjunctivitisAA - Confidence=1 0

and AAContact lens solution allergyAA - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and photophobia is present. Photophobia is generally indicative of a

corneal or iris problem so the only contact lens related diseases affected by

this rule are SLK and solution allergy.

RULE NUMBER: 119

IF:

THE PROBLEM IS CL RELATED

Appendix C-88
and Does your patient complain of any of the following symptoms of

ocular AAirritationAA? Scratchy or foreign body sensation

THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=1 0

and AAContact lens depositAA - Confidence=10

and AAInverted contact lensAA - Confidence=10

and AADamaged contact lensAA - Confidence=1 0

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and a foreign body sensation is present. Several contact lens related

disorders are incremented mildly if this rule fires.

RULE NUMBER: 120

IF:

THE PROBLEM IS CL RELATED

and OD VISION IS REDUCED

or: OS VISION IS REDUCED

THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=1 0

and Contact lens induced AASuperior limbic conjunctivitisAA -

Confidence=10

and AAContact lens depositAA - Confidence=1 0

and AAInverted contact lensAA - Confidence=10

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and V/A in either eye is less than 20/25. Several contact lens related

disorders are incremented mildly if this rule fires.

RULE NUMBER: 121

IF:

THE PROBLEM IS CL RELATED

and Does your patient have an ocular history of any of the following?

Recent or current soft contact lens wear

Appendix C-89
and THE STAIN LOCATION IS PERIPHERAL

and The peripheral corneal staining is predominantly Superior

THEN:

Contact lens induced AASuperior limbic conjunctivitisAA - Confidence=30

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and there is superior peripheral comeal staining. In addition, for this

rule to fire, the patient must be a SOFT lens wearer as only SCL wearers are

subject to SLK. The only contact lens related disorder that would typically

cause this finding is SLK. Thus, if true, this rule increments (+30) to the SLK

register.

RULE NUMBER: 122

IF:

THE PROBLEM IS CL RELATED

and The AAconjunctivaAA appears to be Abnormal

and Are any of the following conjunctival abnormalities present? AAPapillaeAA

THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=30

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and there is papillary hypertrophy of the conjunctiva. The only contact lens related disorder that would typically cause this finding is GPC.

Thus, if true, this rule increments (+30) to the GPC register.

RULE NUMBER: 123

IF:

THE PROBLEM IS CL RELATED

and Are any of the following conjunctival abnormalities present? AARednessAA

or: Does your patient complain of any of these other ocular symptoms?

Redness

Appendix C-90
THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=1 0

and Contact lens induced AASuperior limbic conjunctivitisAA -

Confidence=10

and AAContact lens solution allergyAA - Confidence=1 0

and AAContact lens depositAA - Confidence=10

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and redness is present. Conjunctival injection can be present with virtually all of the contact lens related disorders, but only the four disorders

listed in the THEN part of this rule are incremented (+10).

RULE NUMBER: 124

IF:

THE PROBLEM IS CL RELATED

and THE STAIN LOCATION IS DIFFUSE

and THERE IS PUNCTATE CORNEAL STAINING

and tHE STAIN AMT IS MULTIPLE AREAS

THEN:

AAContact lens solution allergyAA - Confidence=20

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

o~rpsman inputs that he feels the patient's problem is or may be contact lens

related and diffuse punctate corneal staining is present. Of the contact lens

related disorders, solution allergy is the most likely cause of this symptom,

thus its register is incremented (+20) if this rule fires.

RULE NUMBER: 125

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals:

AADepositsAA

THEN:

AAContact lens depositAA - Confidence=50

Appendix C-91
NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the lens is deposited with foreign material. If the lens is

deposited, then the register for CL lens deposit is incremented (+50) to ensure that it is at threshold or higher.

RULE NUMBER: 126

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals:

^ADamaged edgeAA

THEN:

AADamaged contact lensAA - Confidence=50

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the lens edge is damaged or tom. If the lens is damaged,

then the register for damaged contact lens is incremented (+50) to ensure

that it is at threshold or higher.

RULE NUMBER: 127

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals: AAInverted lensAA

THEN:

AAInverted contact lensAA - Confidence=50

NOTE:

This rule is specific for contact lens related conditions. It only fires if the

corpsman inputs that he feels the patient's problem is or may be contact lens

related and that the lens is inverted. If the lens is inverted, then the register

for inverted contact lens is incremented (+50) to ensure that it is at threshold

or higher.

Appendix C-92
RULE NUMBER: 128

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals: NOT

AADepositsAA

THEN:

AAContact lens depositAA - Confidence=-30

NOTE:

This rule decrements the Deposit register if the corpsman examines the lenses and reports no deposits on the lenses.

RULE NUMBER: 129

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals: NOT

AAInverted lensAA

THEN: AAInverted contact lensAA - Confidence=-30

NOTE:

This rule decrements the Inverted CL register if the corpsman examines the

lenses and reports no inversion of the lenses.

RULE NUMBER: 130

IF:

THE PROBLEM IS CL RELATED

and Inspection of the contact lens (removed from the eye) reveals: NOT

AADamaged edgeAA

THEN:

AADamaged contact lensAA - Confidence=-30

Appendix C-93
NOTE:

This rule decrements the Damaged CL register if the corpsman examines

the lenses and reports no damage of the lenses.

RULE NUMBER: 131

IF:

CORNEAL SENSITIVITY SHOULD BE MEASURED

and What were the results of the AAComeal sensitivity testAA? Both corneas are about equally sensitive

THEN:

AAHerpes simplex keratitisAA - Confidence=-1 0

NOTE:

Reduced corneal sensitivity commonly occurs in cases of ocular herpes. Because this test is unfamiliar to most corpsmen, the results may be somewhat

suspect. Thus, while this is an important finding and should possibly be

given a stronger weighting, this rule only decrements the herpes register -10

if corneal sensitivity is equal.

RULE NUMBER: 132

IF:

The condition is affecting: NOT Only the left eye

and CORNEAL SENSITIVITY SHOULD BE MEASURED

and What were the results of the AACorneal sensitivity testAA? Left cornea

more sensitive than right.

THEN:

AAHerpes simplex keratitisAA - Confidence=30

NOTE:

This rule tests whether corneal sensitivity in the right eye is reduced if the

corpsman has input that the condition is affecting the right or both eyes and

certain conditions triggering the corneal sensitivity test are met. If this rule is

true, the Herpes register is incremented (+30).

Appendix C-94
RULE NUMBER: 133

IF:

The condition is affecting: NOT Only the right eye and CORNEAL SENSITIVITY SHOULD BE MEASURED and What were the results of the

AACorneal sensitivity testAA? Right cornea more sensitive than left

THEN:

AAHerpes simplex keratitisAA - Confidence=30

NOTE:

This rule tests whether corneal sensitivity in the left eye is reduced if the

corpsman has input that the condition is affecting the right or both eyes and

certain conditions triggering the corneal sensitivity test are met.. If this rule is

true, the Herpes register is incremented (+30).

RULE NUMBER: 134

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and [lOP OD] > 0

and [lOP OS] > 0

THEN:

AAAcute angle closure glaucomaAA - Confidence=0

NOTE:

The purpose of this rule is to force the runtime to ask the user for lOP

measures of the right and left eye in order if any of the listed signs and

symptoms are present and he has access to a tonometer. It has no effect on

any disease register (it simply adds 0 to the AACG register).

RULE NUMBER: 135

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? No

Appendix C-95
and What were the results of your evaluation of A^tactile tensions^A?

Right eye firmer than left

and The condition is affecting: NOT Only the left eye

THEN:

AAAcute angle closure glaucomaAA - Confidence=20

NOTE:

the purpose of this rule is to help diagnose angle closure glaucoma based on

the measure of tactile tensions. This rule only fires if certain sx are present,

and the corpsman responds that he does not have a tonometer for lOP

measurement. There is a corresponding rule for the other eye. If all conditions are met, this rule fires and increments the glaucoma register (+20). If

any one of the conditions is false, the rule does not fire and effects no disease registers.

RULE NUMBER: 136

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? No

and What were the results of your evaluation of AAtactile tensionsAA? Left

eye firmer than right

and The condition is affecting: NOT Only the right eye

THEN:

AAAcute angle closure glaucomaAA - Confidence=20

NOTE:

The purpose of this rule is to help diagnose angle closure glaucoma based

on the measure of tactile tensions. This rule only fires if certain sx are

present, and the corpsman responds that he does not have a tonometer for

lOP measurement. There is a corresponding rule for the other eye. If all

conditions are met, this rule fires and increments the glaucoma register

(+20). If any one of the conditions is false, the rule does not fire and effects

no disease registers.

Appendix C-96
RULE NUMBER: 137

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and The condition is affecting: NOT Only the left eye

and [lOP OD] > 30

and [lOP OS] < 25

THEN:

AAAcute angle closure glaucomaAA - Confidence=20

NOTE:

This rule and the following rule help to diagnose angle closure glaucoma on

the basis of increased (above 30) lOP in one eye with the other eye being normal. A numeric input is required (as opposed to categorical) for medical

recording purposes. The screen asking for input of lOP readings only appears to the corpsman if certain sx are present and the corpsman tells the

program he has a tonometer available. If any one of these conditions is not

valid, the rule is set to be false and has no effect on any disease register. If

all conditions are met, the rule fires and (+20) is added to the glaucoma

register.

RULE NUMBER: 138

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and The condition is affecting: NOT Only the right eye

and [lOP OS] > 30

and [lOP OD] < 25

THEN:

AAAcute angle closure glaucomaAA - Confidence=20

NOTE:

This rule and the previous rule help to diagnose angle closure glaucoma on

the basis of increased (above 30) lOP in one eye with the other eye being

normal. A numeric input is required (as opposed to categorical) for medical

Appendix C-97
recording purposes. The screen asking for input of lOP readings only appears to the corpsman if certain sx are present and the corpsman tells the

program he has a tonometer available. If any one of these conditions is not

valid, the rule is set to be false and has no effect on any disease register. If

all conditions are met, the rule fires and (+20) is added to the glaucoma

register.

RULE NUMBER: 139

IF:

The condition is affecting: NOT Only the left eye

and lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and [lOP OD] < 25

and [lOP OS] < 25

and [lOP OD] < ([lOP OS] -2)

THEN:

AATraumatic iritisAA - Confidence=20 and AAAcute iritisAA - Confidence=20 and AAChronic iritisAA - Confidence=20

NOTE:

This rule and the following rule test whether a significant reduction of lOP exists in the affected eye to help diagnose iritis. Only one of the two rules can

fire. Often, iritis causes a drop in lOP. The rule only fires if these conditions

are met: (1) symptoms are present suggestive of glaucoma or iritis; (2) the

presentation is unilateral; (3) a tonometer is used to obtain pressures; (4) the

pressure readings are within expected range, i.e. less than 25 mmHG O.U.;

(5) the pressure of the affected eye is more than 2mmHg lower than the fellow eye. If the rule is true, (+20) is incremented to each of the iritis registers.

There is no corresponding rule for tactile tensions because that procedure is

not discriminant enough to aid the diagnosis of iritis.

RULE NUMBER: 140

IF:

The condition is affecting: NOT Only the right eye

and lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

Appendix C-98
and [lOP OD] 25

and [lOP OS] 25

and [lOP OS] ([lOP OD] -2)

THEN:

AATraumatic iritisAA - Confidence=20

and AAAcute idtisAA - Confidence=20

and AAChronic iritisAA - Confidence=20

NOTE:

This rule and the previous rule test whether a significant reduction of lOP exists in the affected eye to help diagnose iritis. Only one of the two rules can

fire. Often, iritis causes a drop in lOP. The rule only fires if these conditions

are met: (1) symptoms are present suggestive of glaucoma or iritis; (2) the

presentation is unilateral; (3) a tonometer is used to obtain pressures; (4) the

pressure readings are within expected range, i.e. less than 25 mmHG O.U.;

(5) the pressure of the affected eye is more than 2mmHg lower than the fellow eye. If the rule is true, (+20) is incremented to each of the iritis registers.

There is no corresponding rule for tactile tensions because that procedure is

not discriminant enough to aid the diagnosis of iritis.

RULE NUMBER: 141

IF:

confrontation VF Should be done

and What were the results of the AAvisual field examinationAA? Abnormal,

right eye

and What were the results of your AAvisual field examinationAA of the

RIGHT eye? AASectoral defectAA

and The condition is affecting: NOT Only the left eye

THEN:

AARetinal detachmentAA - Confidence=30

NOTE:

The purpose of this and the next rule is to help diagnose retinal detachment.

Only one of the two rules will fire. For this rule to fire, certain symptoms

must be present to instantiate the need for a VF examination, only the right

VF must be abnormal, and the abnormality must be a sectorial defect. In addition, the condition must not affect only the left eye. If the rule fires, (+30) is

added to the retinal detachment register.

Appendix C-99
RULE NUMBER: 142

IF:

confrontation VF Should be done

and What were the results of the AAvisual field examinationAA? Abnormal,

left eye

and What were the results of your AAvisual field examinationAA of the

LEFT eye? AASectorial defectAA

and The condition is affecting: NOT Only the right eye

THEN:

AARetinal detachmentAA - Confidence=30

NOTE:

The purpose of this and the previous rule is to help diagnose retinal detachment. Only one of the two rules will fire. For this rule to fire, certain

symptoms must be present to instantiate the need for a VF examination, only

the left VF must be abnormal, and the abnormality must be a sectorial

defect. In addition, the condition must not affect only the right eye. If the

rule fires, (+30) is added to the retinal detachment register.

RULE NUMBER: 143

IF:

confrontation VF Should be done

and What were the results of the AAvisual field examinationAA? Abnormal,

right eye

and What were the results of your AAvisual field examinationAA of the

RIGHT eye? AAGeneral constriction of the visual fieldAA

and The condition is affecting: NOT Only the left eye

THEN:

AAAcute angle closure glaucomaAA - Confidence=10

NOTE:

The purpose of this and the next rule is to help diagnose acute glaucoma.

Only one of the two rules will fire. For this rule to fire, certain symptoms

must be present to instantiate the need for a VF examination, only the right

VF must be abnormal, and the abnormality must be a constriction defect. In

addition, the condition must not affect only the left eye. If the rule fires, (+10)

is added to the angle closure glaucoma register.

Appendix C- 100
RULE NUMBER: 144

IF:

confrontation VF Should be done

and What were the results of the AAvisual field examinationAA? Abnormal,

left eye

and What were the results of your AAvisual field examinationAA of the

LEFT eye? AAGeneral constriction of the visual fieldAA

and The condition is affecting: NOT Only the right eye

THEN:

AAAcute angle closure glaucomaAA - Confidence=1 0

NOTE:

The purpose of this and the previous rule is to help diagnose acute

glaucoma. Only one of the two rules will fire. For this rule to fire, certain

symptoms must be present to instantiate the need for a VF examination, only

the left VF must be abnormal, and the abnormality must be a constriction

defect. In addition, the condition must not affect only the right eye. If the

rule fires, (+10) is added to the angle closure glaucoma register.

RULE NUMBER: 145

IF:

THE PROBLEM IS NOT CL RELATED

and LID EVERSION SHOULD BE PERFORMED

and AAEversionAA of the eyelids reveals: AAPapillaeAA (bumpy or velvety

appearance to upper tarsal conjunctiva)

THEN:

AAAllergic conjunctivitisAA - Confidence=20

NOTE:

The presence of papillae on the upper tarsal conjunctiva indicate an allergic

reaction, so the allergic conjunctivitis register is incremented (+20). The lid

eversion question only fires if a previous rule establishes the need for the

question.

Appendix C-101
RULE NUMBER: 146

IF:

THE PROBLEM IS CL RELATED

and LID EVERSION SHOULD BE PERFORMED

and AAEversionAA of the eyelids reveals: AAPapillaeAA (bumpy or velvety

appearance to upper tarsal conjunctiva)

THEN:

Contact lens induced AAGiant papillary conjunctivitisAA - Confidence=50

and AAAllergic conjunctivitisAA - Confidence=-20

NOTE:

The presence of papillae in a contact lens wearer is highly indicative of GPC.

If this rule fires, the GPC register is incremented (+50) and the allergic conjunctivitis register is decremented (-20) because it is frequently in the differential. The lid eversion question only fires if a previous rule indicates it needs

to be asked.

RULE NUMBER: 147

IF:

lOP SHOULD BE EVALUATED

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and [lOP OD] < 25

and [lOP OS] < 25

THEN:

AAAcute angle closure glaucomaAA - Confidence=-50

NOTE:

If the lOP in both eyes is normal, AACG can be virtually ruled out. This rule

decrements (-50) from the AACG register if pressure is normal.

RULE NUMBER: 148

IF:

lOP SHOULD BE EVALUATED

Appendix C-102
and Were you able to obtain AAlntraocular pressureAA readings from

your patient? No

and What were the results of your evaluation of AAtactile tensionsAA*? Both

eyes equal and normal

THEN:

AAAcute angle closure glaucomaAA - Confidence=-30

NOTE:

If the lOP in both eyes is normal, AACG can be virtually ruled out. Tactile

tensions are considered less reliable than instrument readings so this rule

decrements (-30) from the AACG register if pressure is normal.

RULE NUMBER: 149

IF:

LID EVERSION SHOULD BE PERFORMED

and AAEversionAA of the eyelids reveals: NOT Foreign body

and The cornea is Abnormal

and Are any of the following comeal abnormalities present? NOT Foreign

body present

THEN:

AACorneal foreign bodyAA - Confidence=-30

NOTE:

This rule decrements the corneal foreign body register (-30) if external

evaluation of the eye reveals that no foreign body is present.

RULE NUMBER: 150

IF:

Is there an AAassociated history of ocular traumaAA? No

and FLUORESCIEN STAINING SHOULD BE DONE

and Does the cornea exhibit AAfluorescein stainingAA? No

THEN:

AACorneal foreign bodyAA - Confidence=-30

Appendix C- 103
NOTE:

The purpose of this rule is to decrement foreign body if several key findings

are absent.

RULE NUMBER: 151

IF:

FLUORESCIEN STAINING SHOULD BE DONE

and Does the staining pattern match either of these patterns? None of the

above

and THE STAINED AREA IS NOT LESS THAN 1 MM

or: THE AREA OF STAINING IS NOT LARGER THAN 1 MM

and tHE STAIN AMT IS MULTIPLE AREAS

and THE STAIN LOCATION IS DIFFUSE

THEN:

AAPneumococcal corneal ulcerAA - Confidence=-30

and AAPseudomonas corneal ulcerAA - Confidence=-30

and AACorneal abrasionAA - Confidence=-30

NOTE:

The purpose of this rule is to decrement the ulcer and abrasion registers if

several key findings are missing.

RULE NUMBER: 152

IF:

The pupillary size and response to light appear to be: Abnormal, both eyes

THEN:

PUPILS ABNORMAL OU WARN

ELSE:

PUPILS ABNORMAL OU DON'T WARN

NOTE:

The purpose of this rule is to warn the corpsman that his patient's disease

may not be within the realm of this program if both pupils are abnormal. Except in rare bilateral occurrences of iritis or angle closure, bilateral pupillary

abnormalities generally indicate a condition beyond the scope of this program.

Appendix C-104
RULE NUMBER: 153

IF:

The condition is affecting: Only the right eye

and The pupillary size and response to light appear to be: Abnormal, left

eye

THEN:

PUPIL ABNORMAL LEFT, LATERALITY RIGHT WARN

ELSE:

PUPIL ABNORMAL LEFT, LATERALITY RIGHT DONT WARN

NOTE:

The purpose of this rule is to warn the corpsman if his pupil findings are inconsistent with the laterality of his patient's condition. That is, if he inputs that

the disease is affecting one eye but the pupil is abnormal in the fellow eye,

the pupil findings are ignored and the message pconwarn.txt is displayed at

the end of the run. The user is then invited to recheck his pupil/laterality findings and use the Change and Rerun feature, if necessary, after the program

finishes.

RULE NUMBER: 154

IF:

The condition is affecting: Only the left eye

and The pupillary size and response to light appear to be: Abnormal, right

eye

THEN:

PUPIL ABN RT, LATERALITY LEFT WARN

ELSE:

PUPIL ABN RT, LATERALITY LEFT DON'T WARN

NOTE:

The purpose of this rule is to warn the corpsman if his pupil findings are inconsistent with the laterality of his patient's condition. That is, if he inputs that

the disease is affecting one eye but the pupil is abnormal in the fellow eye,

the pupil findings are ignored and the message pconwam.txt is displayed at

the end of the run. The user is then invited to recheck his pupil/laterality findAppendix C- 105
ings and use the Change and Rerun feature, if necessary, after the program

finishes.

RULE NUMBER: 155

IF:

lOP SHOULD BE EVALUATED

and The condition is affecting: Only the left eye

and Were you able to obtain AAlntraocular pressureAA readings from your

patient? Yes

and [lOP OD] > 25

and [lOP OS] < 25

THEN:

LAT OS, lOP HIGH OD WARN

ELSE:

LAT OS, lOP HIGH OD DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any). In this case, if the lOP is high in the

right eye, but the corpsman indicates the laterality of the condition to be only

the left eye, a warning is generated before the results are displayed.

RULE NUMBER: 156

IF:

lOP SHOULD BE EVALUATED and The condition is affecting: Only the

right eye and Were you able to obtain AAlntraocular pressureAA readings from your patient? Yes

and [lOP OD] < 25

and [lOP OS] > 25

THEN:

LATERALITY OD, HIGH lOP OS WARN

Appendix C-106
ELSE:

LATERALITY OD, HIGH lOP OS DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any). In this case, if the lOP is high in the left

eye, but the corpsman has indicated that the laterality of the condition is only

the right eye, a warning is generated which appears before the results are

displayed.

RULE NUMBER: 157

IF:

confrontation VF Should be done

and The condition is affecting: Only the left eye

and What were the results of the AAvisual field examinationAA? Abnormal,

right eye

THEN:

VISUAL FIELD ABNORMAL OD, LATERALITY OS WARN

ELSE:

VISUAL FIELD ABNORMAL OD, LATERALITY OS DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any).

RULE NUMBER: 158

IF:

confrontation VF Should be done

and The condition is affecting: Only the right eye

and What were the results of the AAvisual field examinationAA? Abnormal,

left eye

Appendix C- 107
THEN:

VISUAL FIELD ABNORMAL OS, LATERALITY OD WARN

ELSE:

VISUAL FIELD ABNORMAL OS, LATERALITY OD DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any).

RULE NUMBER: 159

IF:

The cornea is Normal

and FLUORESCEIN STAINING SHOULD BE DONE

and THE AREA OF STAINING IS LARGER THAN 1 MM

THEN:

CORNEA NORMAL, STAINING ABNORMAL WARN

ELSE:

CORNEA NORMAL, STAINING ABNORMAL DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any).

RULE NUMBER: 160

IF:

lOP SHOULD BE EVALUATED and Were you able to obtain AAIntraocular pressureAA readings from your patient? Yes

and [lOP OD] > 25

and [lOP OS] > 25

THEN:

HIGH lOP OU, WARN

Appendix C-108
ELSE:

HIGH lOP OU, DON'T WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistent with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any). In this case, if the lOP is high in the

both eyes, a warning is generated which appears before the results are displayed.

RULE NUMBER: 161

IF:

confrontation VF Should be done and What were the results of the

AAvisual field examinationAA? Abnormal, both eyes

THEN:

VF ABNORMAL OU WARN

ELSE:

VF ABNORMAL OU DONT WARN

NOTE:

The purpose of this rule is to provide the corpsman with a warning that some

of the data may be inconsistant with the diagnoses this program can make.

The then and else conclusions are tested by the report generator and the appropriate report is produced (if any). In this case, if the visual fields are abnormal in both eyes, a warning is generated which appears before the

results are displayed.

RULE NUMBER: 162

IF:

[CASE NO] = [DX]

THEN:

STOP

NOTE:

This rule is used in automatic testing of the rulebase using data files

Appendix C-109
generated from the PHS POIS ophthalmic database. It can be turned on or

off from the command (re7.cmd) file.

Appendix C- 110
Appendix D

CAOA Screen Definition File
-- tonometer

-SAMEAS schiotz tonometer -- Intraocular pressure measurement

-SAMEAS intraocular pressure -- localized corneal edema

-SAMEAS localized edematous area

-- purulence

-SAMEAS purulent

-- Retinal breaks or detachments

-SAMEAS Retinal detachment

-- Retinal breaks

-SAMEAS Retinal detachment

-V 3

~CLS

-BACKGROUND LTCYAN

-COLOR BLACK

-CLS

-CURSET 0,0

VISUAL ACUITY OD

Please enter the best corrected distance visual acuity of

the right eye:

V/A OD: 20/

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

--COLOR WHITE

Enter the value for visual acuity and press <ENTER>

<?> -details Quit-save <H>-help <Fl >-Keyword

~CURSET 11, 42

-V 4

-CLS

-BACKGROUND LTCYAN

--COLOR BLACK

-CLS

-CURSET 0,0

Appendix D-2
VISUAL ACUITY OS

Please enter the best corrected distance visual acuity of

the left eye:

V/A OS: 20/

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter the value for visual acuity and press <ENTER>

<?>-details Quit-save <H>-help <Fl >-Keyword

-CURSET 11,42

-V1

-CLS

-BACKGROUND LTCYAN

-COLOR BLACK

-CLS

-CURSET 0,0

INTRAOCULAR PRESSURE OD

Please enter theAAintraocular pressureAA of the right eye

in mmHg:

IOP OD:

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter the value for Intraocular Pressure and press <ENTER>

<?>-details Quit-save <H>-help <Fl >-Keyword

-CURSET 11,38

-V2

-CLS

-BACKGROUND LTCYAN

-COLOR BLACK

Appendix D-3
-CLS

-CURSET 0,0

INTRAOCULAR PRESSURE OS

Please enter theAAintraocular pressureAA of the left eye

in mmHg:

lOP OS:

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter the value for Intraocular Pressure and press <ENTER>

<?>-details Quit-save <H>-help <Fl >-Keyword

-CURSET 11,38

-V7

-CLS

-BACKGROUND LTCYAN

-COLOR BLACK

-CLS

-CURSET 0,0

PROVIDER'S IDENTIFICATION NUMBER

Please enter your identification number.

ID NUMBER:

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter your identification number and press <ENTER>

<?>-details Quit-save <H>-help <Fl >-Keyword

-CURSET 11,38 -V 5

-CLS

Appendix D-4
-BACKGROUND LTCYAN

-COLOR BLACK

-CLS

-CURSET 0,0

PATIENT'S IDENTIFICATION NUMBER

Please enter the patient's Identification number.

PATIENT'S ID NUMBER:

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter the Patient's identification number and press <ENTER>

<?>-details Quit-save < H>-help <Fl >-Keyword

-CURSET 11,38 -V 6

-CLS

-BACKGROUND LTCYAN

-COLOR BLACK

-CLS

-CURSET 0,0

PROVIDER'S DIAGNOSIS

Please enter your diagnosis: DIAGNOSIS:

-BORDER 0,2,21,78, RED

-Color BLUE

-CURSET 0,4

EXSYS PRO

-CURSET 22,0

-BACKGROUND BLUE

-COLOR WHITE

Enter the your diagnosis and press <ENTER>

<?>-details Quit-save <H>-help <Fl >-Keyword

-CURSET 11, 39

-Q "always true"

-CLS

Appendix D-5
-COLOR WHITE

-BACKGROUND BLUE

-CLS

TREATMENT PROTOCOLS

Use the F1 key to select the treatment protocol you wish

to view, then press <ENTER>

AAAcute Angle Closure GlaucomaAA

AAAcute lritisAA

AAAllergic ConjunctivitisAA

AABacterial ConjunctivitisAA

ABlepharitisAA

AAChalazionAA

AAChronic IritisAA

AAContact Lens TearAA

AAContact Lens DepositAA

-PRESS ANY KEY

-CLS

TREATMENT PROTOCOLS

Use the F1 key to select the treatment protocol you wish

to view, then press <ENTER>

Contact Lens Induced AASuperior Limbic KeratitisAA

Contact Lens Induced AAGiant Papillary ConjunctivitisAA

AAContact Lens Solution AllergyAA

AAContact Lens InversionAA

AACorneal AbrasionAA

Appendix D-6
AACorneal Foreign BodyAA

AADislocation of the LensAA

AAFlash BurnAA

AAGonococcal ConjunctivitisAA

-PRESS ANY KEY

-CLS

TREATMENT PROTOCOLS

Use the F1 key to select the treatment protocol you wish

to view, then press <ENTER>

AAHerpes Simplex KeratitisAA

AAHordeolumAA

AAHyphemaAA

AAInclusion ConjunctivitisAA

AAOcular Foreign BodyAA

AAOrbital Blowout FractureAA

AAPenetrating Injury to the EyeAA

AAPneumococcal Corneal UlcerAA

AAPseudomonas Corneal UlcerAA

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TREATMENT PROTOCOLS

Use the F1 key to select the treatment protocol you wish

to view, then press <ENTER>

AARetinal DetachmentAA

AARupture of the GlobeAA

Appendix D-7
AASubconjunctival Hemorrhage^A

AATraumatic IritisAA

AAViral ConjunctivitisAA

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Keyword Information-<F1>, Return-<ESC>:

Press <ENTER> to continue: -- PHOTOPHOBIA

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Photophobia

DEFINITION: An abnormal intolerance to light ranging

from mild light sensitivity to severe pain and

AAblepharospasmhA.

BACKGROUND: Photophobia is generally caused by

AAtrgeminalAA irritation due to ciliary spasm and/or corneal involvement. Photophobia is common in conditions

which affect the cornea, such as Corneal Abrasions, Corneal Ulcers and Viral Conjunctivitis. It is also a common

symptom of diseases affecting the iris and ciliary body,

such as Iritis and Acute Glaucoma.

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-- BLEPHAROSPASM

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Appendix D-8
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Blepharospasm

DEFINITION: Tonic spasm of the orbicularis oculi

muscle, producing more or less complete closure of the

eyelids. Symptomatic blepharospasm occurs in association with a lesion of the eye or of the AAtrigeminalAA nerve.

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-- Corneal Abrasion

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CONDITION: Corneal Abrasion

STRUCTURES INVOLVED: Cornea

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS: Pain, usually worse with blink

OTHER SYMPTOMS: AAPhotophobiaAA

HALLMARK SIGNS:

OTHER SIGNS: AAWeepingAA, conjunctival injection, history of

ocular exposure to causative agent (wind, paper, foreign body, contact

lens), history of recurrent corneal erosion

DIAGNOSTIC PROCEDURES: Examine affected eye with white

light, large abrasions may be visible. Instill ^^fluorescein^^ and re-examine with UV light, abrasion will stain and appear bright green under

UV illumination. Check for

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Appendix D-9
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presence of foreign body and remove if necessary.

TREATMENT: Instill broad spectrum antibiotic ointment (sulfacetamide

or neosporin) and patch affected eye, if necessary for comfort, for 24h.

If pain is severe, in- still cycloplegic agent (atropine 1% 2 drops) and

prescribe systemic analgesic (Tylenol) in addition to antibiotic and

patching. Ught duty or bed rest as needed for 24h. Patient should

be instructed to minimize eye movement as much as possible (i.e.

avoid reading. TV is OK)

PROGNOSIS: Usually full recovery is expected within 24h. Occasionally, a patient may experience recurrent corneal erosions in the same

area the abrasion occurred. These patients should receive the same

treatment for recurrencesand be referred to an ophthalmologist when

convenient.

CL CONSIDERATIONS: Both Soft and Hard contact lenses can be the

causative agent in cases of corneal abrasion. If

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contact lenses are the suspected cause, ""inspect the lenses"" with

magnification. Look for tears or irregular edges. If the lenses are

defective, discontinue lens wear, use new lenses if available after complete corneal recovery. If the lens appears to be deposited with

protein or other material, instruct patient to clean lenses and use enzyme cleaner if appropriate. Re-inspect lens after cleaning. If foreign

material is successfully removed, the lenses can be reinserted after

complete recovery of the abrasion. If the foreign material is still

present after cleaning, discontinue contact lens wear, use new lenses

if available.

Appendix D-10
Primary Source: TRAINING MANUAL FOR SUBMARINE IDC'S

Secondary Source: Newell, Ophthalmology: Principles and Concepts,

Mosby, St.Louis: 1978

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-- contact lens tear

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CONDITION: Contact lens tear

STRUCTURES INVOLVED: Cornea

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Blurred vision, scratchy sensation-especially

with blinking.

HALLMARK SIGNS: Damaged lens on inspection

OTHER SIGNS: ""Weeping"", conjunctival injection,

DIAGNOSTIC PROCEDURES: ""Carefully examine both contact lenses"" using your Wood's lamp or any other magnifier. Look at the

edges of the lenses as well as the the central portion. Tears and

cracks can be very difficult to see.

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TREATMENT: The only treatment for a contact lens tear is to replace

the contact lens or discontinue contact lens wear altogether. It is also

Appendix D- 11
important to rule out ""corneal abrasion"" which sometimes may accompany a torn lens. The patient should be instructed on proper lens

handling procedures.

PROGNOSIS: Usually lens replacement or removal will result in complete recovery. If symptoms persist, be alert to other conditions which

may also be present, such as ""contact lens deposits"", ""contact lens

inversion"", or ""corneal abrasion"".

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-- contact lens deposit

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CONDITION: Contact lens ""deposits""

STRUCTURES INVOLVED: Cornea

LATERALITY: Usually bilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Blurred vision, scratchy sensation-especially

with blinking.

HALLMARK SIGNS: Deposited lens on inspection

OTHER SIGNS: ""Weeping"", conjunctival injection,

DIAGNOSTIC PROCEDURES: ""Carefully examine both contact lenses"" using your Wood's lamp or any other magnifier. Look at both

the front and back surfaces of the lenses. Most deposits will occur

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Appendix D- 12
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on the front surface. Protein deposits will give the lens a hazy appearance under white light and magnification. Lipid ""deposits""

sometimes look like bumps of clear jelly on the surface of the lens.

Mineral deposits usually appear to be hard white spots on the lens surface.

TREATMENT: Occasionally, enzyme and surfactant cleaning of the

lenses is sufficient to eliminate lens deposits, especially if they are

composed of protein. If cleaning fails, the only alternatives are to

replace the lens or discontinue lens wear altogether. It is also important to rule out ""corneal abrasion"" which sometimes may accompany severely deposited lenses. The patient should be instructed on

proper lens hygiene.

PROGNOSIS: Usually lens replacement or removal will result in complete recovery. If symptoms persist, be alert to other conditions which

may also be present, such as ""contact lens tear"", ""contact lens inversion"", or ""comeal abrasion"".

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-- solution allergy

-SAMEAS contact lens solution allergy

-- contact lens solution allergy

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CONDITION: Contact lens solution allergy

STRUCTURES INVOLVED: Cornea, ""conjunctiva"", lids

LATERALITY: Usually bilateral

HALLMARK SYMPTOMS: Itching, especially when wearing lenses

OTHER SYMPTOMS: scratchy sensation-especially with blinking.

Appendix D- 13
HALLMARK SIGNS:

OTHER SIGNS: conjunctival injection, conjunctival ""edema"", lid

edema, ""stringy"" or ropey white ^"discharge"", ""weeping"".

DIAGNOSTIC PROCEDURES: ""Wright's stain"" of conjunctival

scraping may reveal increased ""eosinophils"" indicating a allergic

response. Check the patient's contact lens solutions for ""preservatives"",

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especially those which are frequently associated with solution allergy.

TREATMENT: The only satisfactory treatment for a contact lens

solution allergy is to change to solutions containing different (or no)

preservatives and to replace the lenses. Since this is impractical while

underway, lens wear must be discontinued and the patient should be

referred to an optometrist when convenient.

PROGNOSIS: Usually, removal of the lenses will result in complete

recovery within 24 hours. If symptoms persist, be alert to other conditions which may also be present, such as ""allergic conjunctivitis"A, ""^viral conjunctivitis"", ""bacterial conjunctivitis"A, or ""corneal

abrasion"".

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-- contact lens inversion

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Appendix D-14
CONDITION: Contact lens inversion

STRUCTURES INVOLVED: Cornea

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Blurred vision, scratchy sensation-especially

with blinking.

HALLMARK SIGNS: Inverted lens on inspection

OTHER SIGNS: ""Weeping"", conjunctival injection,

DIAGNOSTIC PROCEDURES: ""Carefully examine both contact lenses"" using your Wood's lamp or any other magnifier. Hold each lens

on your fingertip and view it from the side. Try to determine if the lens

contours consistently up to the edge. If the edge of the

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lens reflects slightly outward, an inverted lens is indicated.

TREATMENT: Reverting the lens to right-side-out usually will correct

the problem. It is also important to rule out ""corneal abrasion"" and

""^contact lens tear"" which sometimes may accompany inverted lenses. While hard or gas-permeable lenses may sometimes be inverted,

they usually are damaged to the point that lens wear is contraindicated. The patient should be instructed on proper lens handling procedures.

PROGNOSIS: Usually, returning the lens to right-side-out will result in

complete recovery. If symptoms persist, be alert to other conditions

which may also be present, such as ""contact lens tear"", or ""corneal

abrasion"".

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Appendix D-15
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MEDIC Hypertext Help System -- hyperacute conjunctivitis

-SAMEAS gonococcal conjunctivitis

-- gonococcal conjunctivitis

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CONDITION: Gonococcal conjunctivitis (hyperacute conjunctivitis)

STRUCTURES INVOLVED: Cornea, ""conjunctiva""

LATERALITY: Either unilateral or bilateral

HALLMARK SYMPTOMS: Positive venereal history

OTHER SYMPTOMS: Eyes tender, painful. Blurred vision due to

""Adischarge"", extremely rapid ""onset"A--can be very alarming

HALLMARK SIGNS: Severe ""purulent"" discharge

OTHER SIGNS: severe conjunctival injection, ""chemosis"", ballooning of lids due to copious discharge, reduced visual acuity, swollen

""Apre-auricular nodes""

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DIAGNOSTIC PROCEDURES: Do an immediate ""Gram's stain^"

looking for Gram negative intracellular diplococci to confirm diagnosis.

TREATMENT: Rapid aggressive treatment is necessary. 1. Eye

irrigation with saline qid until the ""discharge"" is eliminated. 2. Topical bacitracin or erythromycin ointment qid. 3. Treat systemically as

for venereal GC (e.g. Ceftiaxone 1 g iv q 12h for at least three days--

longer depending on clinical response). 4. Tetracycline or

Appendix D- 16
erythromycin 250-500 mg po qid x 2-3 weeks (treatment for chlamydia,

which may also be present).

PROGNOSIS: Varies with rapidity of appropriate treatment.

Purulence usually calms in about 48 hours with proper treatment.

The conjunctivitis may last 1-2 weeks.

CL CONSIDERATIONS: Discontinue contact lens wear until advised

by optometry or ophthalmology

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Primary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

Secondary Source: SCCO, Therapeutic Management of Ocular Conditions, SCCO, Fullerton, CA: 1989

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-- inclusion conjunctivitis

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CONDITION: Chlamydial Inclusion Conjunctivitis

STRUCTURES INVOLVED: Comea, ""conjunctiva""

LATERALITY: Either unilateral or bilateral

HALLMARK SYMPTOMS: Positive venereal history

Appendix D-17
OTHER SYMPTOMS: Eyes stuck together in the morning,

""photophobia"", scratchy or foreign body sensation, variable onset--

can be acute to insidious.

HALLMARK SIGNS:

OTHER SIGNS: Conjunctival injection, ""follicles"" form especially

in lower ""palpebral conjunctiva"", ""papillae"" especially in superior

palpebral conjunctiva, ""mucopurulent"" ""discharge"", tender

""^pre-auricular nodes"", superior corneal ""infiltrates"".

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DIAGNOSTIC PROCEDURES: ""Wright's stain"" may show increased ""neutrophils"^ and ""lymphocytes"".

TREATMENT: Tetracycline or erythromycin 250-500 mg po qid for

3-6 weeks depending on clinical response. Erythromycin,

tetracycline or sulfacetamide ointment 2-3 X day for 2-3 weeks.

PROGNOSIS: With appropriate treatment, usually lasts

depending on severity.

CL CONSIDERATIONS: Discontinue contact lens wear

by optometry or ophthalmology.

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1-3 weeks,

until advised

Primary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

Appendix D-18
Secondary Source: SCCO, Therapeutic Management of Ocular Conditions, SCCO, Fullerton, CA: 1989

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---corneal foreign body

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CONDITION: Corneal Foreign Body

STRUCTURES INVOLVED: Cornea, ""conjunctiva"", lids

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS: History of a foreign body to the eye

OTHER SYMPTOMS: Scratchy or foreign body sensation, tearing, ""^photophobia"", blurred vision.

HALLMARK SIGNS: Corneal foreign body, rust ring, or both.

OTHER SIGNS: Conjunctival injection, eyelid ""edema"", mild

""^anterior chamber"" reaction (iritis), and superficial punctate keratitis.

A small ""infiltrate"" may surround the foreign body, especially if the

foreign body has been present in the eye for more than 24 hours.

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DIAGNOSTIC PROCEDURES: Consider the possibility of a penetrating foreign body especially if the foreign body arose from metal

striking metal. Locate the foreign body using your Wood's lamp

and fluorescein. ""Evert"" the eyelids and examine each conjunctival ""^fomix"" for additional foreign bodies.

Appendix D- 19
TREATMENT: Remove the corneal foreign body: Apply a topical anesthetic. Remove the foreign body with a foreign body spud or a 25

gauge needle under magnification (it may be necessary to recruit an

assistant to hold the Wood's lamp or other magnifier). Instill a

cycloplegic (cyclopentalate 2%, or homatropine 5%) and an antibiotic

ointment (e.g. erythromycin). Pressure patch for 24 hours. Note: An

""^infiltrate"" accompanied by a significant ""anterior chamber"" reaction should be treated with antibiotics more aggressively.

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PROGNOSIS: A. A small (< 1-2 mm diameter in size), clean, noncentral epithelial defect present after foreign body removal:

Remove the patch after 24 hours, and re-examine the cornea. If

the eye is stable or improving, begin topical antibiotics for 3-4 days

(e.g. sulfacetamide drops qid or erythromycin ointment 2-3 times a

day). B. If the resulting epithelial defect is central or large (> 2mm in

diameter), follow-up every 24 hours and consider more aggressive antibiotic treatment.

CL CONSIDERATIONS: Discontinue contact lens wear until full

recovery is achieved--usually in about 1 week in uncomplicated cases.

Primary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

Secondary Source: SCCO, Therapeutic Management of Ocular Conditions, SCCO, Fullerton, CA: 1989

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-- subconjunctival hemorrhage

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Appendix D-20
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CONDITION: Subconjunctival Hemorrhage

STRUCTURES INVOLVED: ""Conjunctiva""

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS: Red eye, usually abrupt ""onset"".

OTHER SYMPTOMS: May have mild irritation.

HALLMARK SIGNS: Blood underneath conjunctiva, often in a sector

of the eye. Following trauma, the entire view of the sclera may be

obstructed by the blood.

OTHER SIGNS:

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DIAGNOSTIC PROCEDURES: Try to determine etiology: Was it

caused by eye rubbing, trauma, heavy lifting, valsalva, or by systemic

disease such as hypertension or diabetes? Has the patient had a

recent URI or cold (sneezing and coughing can be the cause of a subconjunctival hemorrhage)? In traumatic cases, rule out a ""rupture of

the globe"". Check your patient's blood pressure. If the patient has a

history of recurrent subconjunctival hemorrhages or a history of bleeding problems, refer him to your medical officer.

TREATMENT: Reassurance. Otherwise none required.

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Appendix D-21
PROGNOSIS: This condition usually recovers spontaneously

within 1-3 weeks, depending on severity. Have your patient return if

the blood does not fully resolve, or if they suffer a recurrence. Refer to

SMO as indicated for hypertension or bleeding disorders.

CL CONSIDERATIONS: Discontinue contact lens wear until full

recovery is achieved.

Primary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

Secondary Source: SCCO, Therapeutic Management of Ocular Conditions, SCCO, Fullerton, CA: 1989

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CONDITION: Contact Lens Induced Giant Papillary Conjunctivitis

STRUCTURES INVOLVED: ""Conjunctiva""

LATERALITY: Usually bilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Itching, ""mucoid"" ""discharge"", decreased

lens wearing time, increased lens awareness, excessive lens

movement.

HALLMARK SIGNS: ""Papillae"" on the superior ""tarsal conjunctiva"".

OTHER SIGNS: Contact lens ""deposits"", high riding lens, drooping

eyelids, mild conjunctival injection.

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Appendix D-22
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DIAGNOSTIC PROCEDURES: "^Evert"" the upper eyelids to examine for ""papillae"". Sometimes, the papillae are more visible if

""^fluorescein"" is instilled in the eye.

TREATMENT: Replace the contact lenses if there are significant ""^deposits"". Reduce wearing time (switch extended wear patients

to daily wear). Have patient clean and enzyme his lenses more

carefully. Alternatively, discontinue contact lens wear, especially with

severe cases.

PROGNOSIS: This condition is difficult to treat effectively, especially

while underway. Refer to optometry when convenient for possible refit

to gas permeable lenses or other treatment.

Primary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

Secondary Source: Efron and Holden, A Review of Some Common Contact Lens Complications, Optician 192:21-26;1986

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MEDIC Hypertext Help System -- superior limbic conjunctivitis

-SAMEAS superior limbic keratitis

-- superior limbic keratitis

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CONDITION: Contact Lens Induced Superior Limbic Kerato-Conjunctivitis

STRUCTURES INVOLVED: ^^Conjunctiva"", Cornea

Appendix D-23
LATERALITY: Usually bilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Itching/burning, increased lens awareness,

slightly blurred vision, ""photophobia"".

HALLMARK SIGNS: Hyperemia of the superior ""bulbar conjunctiva"^

just above the limbus.

OTHER SIGNS: Superior corneal ""infiltrates"", corneal and conjunctival staining, hazy appearance to superior peripheral cornea.

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DIAGNOSTIC PROCEDURES: ""Fluorescein"" dye may reveal

punctate (pinpoint) staining of the superior 1/3 of the cornea.

TREATMENT: Cease lens wear until ""inflammation"" subsides. An

ocular lubricant may provide some symptomatic relief. PROGNOSIS:

This condition usually clears up 1-2 weeks after lens removal. If lens

wear is then reintroduced, a recurrence is fairly likely. Refer to optometry when convenient for possible refit to gas permeable lenses or

other treatment.

Primary Source: Efron and Holden, A Review of Some Common Contact Lens Complications, Optician 192:21-26;1986

Secondary Source: Friedberg and Rapuano, Office and Emergency

Room Diagnosis and Treatment of Eye Disease, Lippincott, Philadelphia: 1990

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-- FLASH BURN

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Appendix D-24
-BACKGROUND BLUE

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CONDITION: Flash Burn

STRUCTURES INVOLVED: Cornea, ""conjunctiva""

LATERALITY: Usually bilateral

HALLMARK SYMPTOMS: Severe pain 6-12 hours after exposure to

welding arc.

OTHER SYMPTOMS: ""Photophobia""

HALLMARK SIGNS:

OTHER SIGNS: Conjunctival injection and ""chemosis""

TREATMENT: Reassurance. Cycloplegia and mydriasys with Atropine

1%, 2 drops in each affected eye q 24h. Broad spectrum antibiotic ointment (Neosporin) as prophylaxis for secondary infection. Systemic analgesic (tylenol). If pain is severe, bilateral or alternate eye patching for 24 hr. Bed rest.

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PROGNOSIS: Expect complete recovery within 24-48 hours.

CL CONSIDERATIONS: Discontinue contact lens wear until 24h after

complete corneal recovery.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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Appendix D-25
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CONDITION: Pneumococcal (Acute Serpiginous) Corneal Ulcer

STRUCTURES INVOLVED: Cornea, "^conjunctiva""

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Pain, blurred vision, ""photophobia""

HALLMARK SIGNS: Whitish gray ulceration of cornea, may be single

or multiple sites, with overhanging margins, accompanied by hypopyon (pus in the anterior chamber). Usually secondary to

trauma (e.g. ""comeal abrasion"A) or extended contact lens wear.

OTHER SIGNS: Severe conjunctival injection, ^"chemosisA", ""weeping"", hypopyon, reduced visual acuity

DIAGNOSTIC PROCEDURES:

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TREATMENT: Rapid aggressive treatment with local antibiotics (Sulfacetamide 10% 2 drops q2h during waking hours and neosporin ointment at bed time). Medevac as soon as possible.

PROGNOSIS: Varies with rapidity of appropriate treatment, location of ulcer, and virility of causative agent. May resolve with no permanent damage, may resolve with corneal scarring and associated

Appendix D-26
reduction in visual acuity, or in the worst case, the ulcer may perforate

and leave the patient with a phthisic eye.

CL CONSIDERATIONS: Improper contact lens hygiene, the use of

non-sterile contact lens solutions (home-made saline, tap water),

over wear of extended wear contact lenses can predispose a

patient to corneal ulceration. Contact lens wear is contraindicated if a patient develops a corneal ulcer unless directed by

higher authority.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source:

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-- OCULAR FOREIGN BODY

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CONDITION: Ocular Foreign Body

STRUCTURES INVOLVED: Cornea, ""Conjunctiva"", Lids

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS: Acute onset of scratchy sensation in eye

OTHER SYMPTOMS: Pain, ""photophobia"", excessive tearing.

HALLMARK SIGNS: History of exposure to foreign body source, Foreign body tracking stain pattern on cornea.

OTHER SIGNS: ""corneal abrasion"", conjunctival injection,

chemosis, ""weeping"", blepharospasm

DIAGNOSTIC PROCEDURES: Examine affected eye with white light

and magnifier. If foreign body is not detected, instill fluorescein

Appendix D-27
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and inspect with UV light (woods lamp). ""Evert"" superior eye lid,

examine tarsal conjunctival surfaces and conjunctival ""fornix"" of

both superior and inferior lid.

TREATMENT: Topical anesthesia may be necessary depending on

location of FB and severity of pain. Attempt to remove superficial

FB with sterile saline irrigation. If unsuccessful, try sterile saline wetted

cotton tipped applicator. If still unsuccessful, can attempt removal with

sterile 26 gauge needle or spud. Re-examine with UV light for corneal

staining (may need to re-instill Fluorescein). If no corneal staining,

prescribe sulfacetamide 10%, 2 drops in affected eye q4h x24h. Reexamine in 24h or prm. If corneal staining is present, instill 2 drops Atropine 1 % and broad spectrum antibiotic ointment (neosporin) in the

affected eye, patch eye for 24h. Re-examine in 24h or prn. If foreign

body is embedded, medevac as soon as possible.

PROGNOSIS: If FB is successfully removed, and the cornea is not

compromised, recovery is usually immediate. ""corneal abrasion""

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CL CONSIDERATIONS: Occasionally, a soft contact lens problem can

mimic a foreign body. Edge tears in soft lenses, rough or uneven

edges in hard lenses, and ""deposits"" on either can produce a FB

sensation. The lenses should be examined for deposits and defects. If

found to be defective, lens wear should be discontinued unless

suitable replacement lenses are available. If the lenses are deposited,

they should be cleaned with surfactant and enzyme cleaner if

Appendix D-28
appropriate and re-inspected prior to reinsertion. In any case, lens

wear should be discontinued until 24h after complete recovery.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- HERPES KERATITIS

-SAMEAS herpes simplex keratitis -- HERPES SIMPLEX KERATITIS

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CONDITION: Herpes Simplex Corneal Ulcer

STRUCTURES INVOLVED: Cornea, ""conjunctiva""

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Pain, blurred vision, ""Photophobia""

HALLMARK SIGNS: ""Dendritic"A (branches like a tree) ulceration of

cornea. (Note: Early in the course of a Herpes infection, only a few

punctate opacities may appear which later coalesce into the typical

branching pattern.) If untreated, a dense disciform lesion may result.

OTHER SIGNS: Conjunctival injection, history of previous episodes,

history of cold sores. recent history of stress (e.g. emotional or physical stress, fever). Corneal anesthesia, reduced visual acuity.

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Appendix D-29
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DIAGNOSTIC PROCEDURES: Instill ""fluorescein"" and examine

with UV light. Fluorescein will stain only those vesicles which have ruptured, creating patchy areas of staining over the underlying gray

dendritic ulcer. If the condition appears to be unilateral, you can help

confirm a Herpes simplex diagnosis by testing for corrneal anesthesia

(an ocular herpes infection generally causes reduced corneal sensitivity). ""Test for corneal anesthesia"" using a cotton tipped applicator. Pull part of the cotton swab off to form a small wisp of cotton.

Have the patient look up while you gently touch the cotton wisp to the

inferior portion of the cornea of the unaffected eye. Note the patients

reaction. Then touch the cotton wisp in a similar manner to the inferior

portion of the affected eye. Again note the reaction. Ask the patient

which eye seemed to feel more irritation. In cases of Herpes Simplex,

the affected cornea is usually much less sensitive than the unaffected

eye.

TREATMENT: Prescribe antiviral ointment (Acyclovir) q2-4h, depending on severity, for the affected eye until resolved. Medevac as

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soon as possible.

PROGNOSIS: If treatment is effective, eye and vision will return to normal. Corneal scarring may occur leading to reduced visual acuity.

Usually, patients with ocular herpes simplex will suffer recurrences

especially when in stressful situations.

CL CONSIDERATIONS: Discontinue contact lens wear until directed

otherwise by higher authority.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Appendix D-30
Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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"--PSEUDOMONAS CORNEAL ULCER

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CONDITION: Pseudomonas Corneal Ulcer

STRUCTURES INVOLVED: Cornea, ""conjunctiva""

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Pain, Conjunctival injection, ""Photophobia"",

Blurred vision

HALLMARK SIGNS: Blue-Green colored ""discharge"" at ulcer sight

is pathognomonic

OTHER SIGNS: White Gray circumscribed comeal ulceration, injec- tion, reduced visual acuity

DIAGNOSTIC PROCEDURES: ""Fluorescein"" Staining will help identify sight of ulcer. ""Gram's stain"" will reveal Gram negative rods.

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TREATMENT: Gentamicin Ophthalmic ointment q1 h during the day,

q2h at night if the ulcer is small and shallow (< 2 mm in size). If ulcer

Appendix D- 31
is 2-5 mm in size, use Gentamicin drops q 15 minutes. In any case,

medevac or refer as soon as possible--may cause corneal perforation

and loss of an eye in as little as 48 hours.

PROGNOSIS: Depending on effectiveness of treatment, pseudomonas can result in minor corneal scarring to loss of vision and even

loss of an eye. THIS DISEASE CAN RESULT IN CORNEAL PERFORATION AND LOSS OF AN EYE WITHIN 48 HOURS OF ONSET.

CL CONSIDERATIONS: Discontinue lens wear. Pseudomonas infections appear to be related to contact lens wear and particularly with

mishandling of lenses (i.e. overwear, improper lens hygiene, etc.)

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Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- HYPHEMA

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CONDITION: Hyphema

STRUCTURES INVOLVED: ""Anterior Chamber"", iris, cornea

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

Appendix D-32
OTHER SYMPTOMS: Pain may be present,

HALLMARK SIGNS: pooling of blood in the anterior chamber (between

iris and cornea, usually inferior).

OTHER SIGNS: History of trauma or injury, (rarely, hyphema can

occur with uveitis, or may be idiopathic) may cause increased

""^intraocular pressure"" in affected eye, reduced visual acuity.

DIAGNOSTIC PROCEDURES: As a secondary glaucoma may result

from hyphema, monitor lOP with ""tonometer"" if available.

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TREATMENT: Bed rest with head in 30 degree elevated position.

Avoid activities which require excessive eye movement (e.g. reading) or that tend to increase blood pressure (exercise, lifting, etc.)

PROGNOSIS: If only a small amount of blood (less than 1/3 of the

""^anterior chamber"" filled with blood) has leaked into anterior

chamber, and lOP is unaffected, the condition will usually resolve

within 1 to 2 weeks. If lOP increases significantly (greater than 30

mmHg), secondary glaucoma may result, leading to loss of vision. Because hyphema can be a sign of major intraocular trauma, the prudent IDC may choose to medevac all but the most clearly uncomplicated

cases.

CL CONSIDERATIONS: Discontinue CL wear until condition is completely resolved.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: 1. Duane TD, ed. Clinical Ophthalmology Philadel-

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Appendix D-33
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phia: Harper and Row, 1981. 2. Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- TRAUMATIC IRITIS

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CONDITION: Traumatic Iritis

STRUCTURES INVOLVED: lris, ""Anterior Chamber"", ""Conjunctiva""

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Pain, ""photophobia"", Blurred vision

HALLMARK SIGNS:

OTHER SIGNS: History of usually blunt trauma to eye, sluggish, miotic

pupil in affected eye, possible slight clouding of aqueous humor of

anterior chamber, ""diffuse"" injection of conjunctiva which may appear to increase around cornea (""circumcorneal"" injection), reduced

visual acuity

DIAGNOSTIC PROCEDURES: 1. Examine the pupils carefully with a

penlight. The affected eye will generally have a reduced and slow

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Appendix D-34
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direct and consensual pupillary response to light. 2. In normal room

light, the pupil of the affected eye is usually slightly smaller than the unaffected eye. 3. The patient may complain of pain in the affected eye

when light is shined on the unaffected eye. 4. In a darkened room, examine the appearance of the contents of the ""anterior chamber"" of

both eyes with white light directed from the side. The fluid in the

anterior chamber of the affected eye may appear slightly cloudy relative to the unaffected eye.

TREATMENT: If the condition is mild, treatment with mydriatics

(atropine) may be sufficient. In moderate and severe cases, topical

steroids should be employed, but with appropriate caution. Systemic

analgesics (tylenol) may be administered for pain. Unless the

corpsman is convinced that no complicating factors associated with

trauma are present (retinal detachment, macular ""edema"", ""^hyphema"", etc.), the patient should be medevaced or referred as

soon as possible.

PROGNOSIS: If traumatic iritis is uncomplicated, the patient

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will usually recover within one week.

CL CONSIDERATIONS: Discontinue contact lens wear until eye is

fully recovered.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Duane TD, ed. Clinical Ophthalmology Philadelphia: Harper and Row, 1981.

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Appendix D-35
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-- ACUTE IRITIS

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CONDITION: Acute (Non granulomatous) Uveitis (Iritis)

STRUCTURES INVOLVED: Iris, ""Anterior Chamber"", ""Conjunctiva"", Ciliary Body, Anterior Choroid.

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Abrupt onset of moderate to severe pain, ""^photophobia"", redness, and blurred vision.

HALLMARK SIGNS: Many cells and aqueous flare in anterior chamber

OTHER SIGNS: Pinpoint keratic precipitates, generalized retinal

""^edema"", abrupt reduction in visual acuity, vitreous clouding,

ciliary vessel injection, particularly ""circumcorneal"". Pupil may

be mid-dilated and sluggish.

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DIAGNOSTIC PROCEDURES: In a darkened room, examine the appearance of the contents of the ""anterior chamber"" of both eyes with

white light directed from the side. The fluid in the anterior chamber of

the affected eye may appear slightly cloudy relative to the unaffected

eye. Ophthalmoscopy may reveal vitreous clouding if the

posterior uvea is involved.

Appendix D-36
TREATMENT: The iris should be immobilized by mydriatics

(atropine). In addition, topical steroids should be employed, but with

appropriate caution. Systemic steroids are the main treatment in

cases of uveitis involving the posterior uvea. Systemic analgesics

(tylenol) may be administered for pain. Unless the corpsman is convinced that no complicating factors are present and the case is extremely mild, the patient should be medevaced or referred as soon as

possible.

PROGNOSIS: Acute uveitis is usually self limited (1 to 6 weeks) but is

often recurrent.

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CL CONSIDERATIONS: Discontinue CL wear until otherwise advised

by higher authority.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- CHRONIC IRITIS

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CONDITION: Chronic (Granulomatous) Uveitis (Iritis)

STRUCTURES INVOLVED: Iris, Conjunctiva, ""Anterior Chamber"",

Ciliary Body, Anterior Choroid.

Appendix D-37
LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Gradual onset of blurred vision, slight or no

pain or ""photophobia"", mild redness.

HALLMARK SIGNS: Large mutton fat keratic precipitates, iris

nodules.

OTHER SIGNS: Mild ""circumcomeal"" injection of ciliary vessels,

iris precipitates, little aqueous flare, vitreous clouding, choroidal inflammation.

DIAGNOSTIC PROCEDURES: Careful examination of posterior corneal

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surface (endothelium) with a penlight and magnifying loupe may

reveal large (0.5 mm) white spots which are keratic precipitates.

The iris may exhibit patchy atrophy and nodules. Fundus examination may reveal large areas of choroidal ""edema"" which appear as

patches of white of gray areas surrounded by normal retina. The

vitreous may appear cloudy.

TREATMENT: The iris should be immobilized by mydriatics

(atropine). In addition topical steroids should be employed at frequent

intervals, but with appropriate caution. If the posterior uvea is involved, systemic steroids are the main treatment. Because these

cases are usually difficult to manage, the patient should be

medevaced or referred as soon as possible.

PROGNOSIS: Chronic uveitis often runs a protracted course with exacerbations and remissions. Often retinal scarring occurs as a sequelae to

posterior uveitis.

CL CONSIDERATIONS: Discontinue CL wear until otherwise advised

by higher authority.

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Appendix D-38
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Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- ACUTE ANGLE CLOSURE GLAUCOMA

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CONDITION: Acute Angle Closure Glaucoma

STRUCTURES INVOLVED: Conjunctiva, Cornea, ""Anterior Chamber"", Iris

LATERALITY: Usually unilateral (Both eyes are involved, but

usually one becomes symptomatic before the other)

HALLMARK SYMPTOMS: Severe Pain

OTHER SYMPTOMS: Blurred vision, halo's around lights, ""Aphotophobia"A, nausea, cephalgia, redness, tearing.

HALLMARK SIGNS: Increased ""intraocular pressure"" (greater than

30 mmHG), eye feels rock hard to digital palpation.

OTHER SIGNS: Mid-dilated unresponsive pupil in affected eye, circumcorneal injection of the ciliary vessels, edematous cornea

(may appear "dull" or "steamy" or "fogged"), reduced visual acuity,

usually occurs in hyperopes, profuse ""weepingA".

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Appendix D-39
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DIAGNOSTIC PROCEDURES: 1. Measure intraocular pressure.

Preferably, with a ""tonometer^", but ""tactile tensions"" may reveal a

significant difference between the affected and unaffected eye, with

the glaucomatous eye being significantly more firm than the normal

eye.

TREATMENT: Osmotic agents may be used systemically to reduce intraocular pressure. Urea or mannitol can be administered iIntravenously. Glycerol can be administered orally (if patient is already

nauseas, oral glycerol may worsen the situation). 2. Pilocarpine ophthalmic solution should be administered to the affected eye, 1 drop q 5

minutes until the pupil becomes miotic. Diamox should be administered orally if available. Medevac or refer as soon as possible.

PROGNOSIS: If early treatment is successful, and the patient

receives timely secondary care, there may be little permanent

damage to the eye. If not successful, vision in the glaucomatous eye

will be lost.

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CL CONSIDERATIONS: Remove contact lenses prior to treatment.

Discontinue contact lens wear.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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Appendix D-40
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-- RUPTURE OF THE GLOBE

-BACKGROUND BLUE

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CONDITION: Rupture of the Globe

STRUCTURES INVOLVED: Cornea, ""Conjunctiva"", Sclera

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS: Blindness

OTHER SYMPTOMS: Pain,

HALLMARK SIGNS: History of blunt trauma, Phthisic (soft) eye

OTHER SIGNS: History consistent with severe trauma to eye,

""hyphema"", markedly reduced visual acuity (finger counting, light

perception).

DIAGNOSTIC PROCEDURES: Very gently

tured eye will lack elasticity.

TREATMENT: Systemic antibiotics, topical

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palpate eye digitally, a rupantibiotics, tetanus

inoculation. Use eye shield on affected eye, patch fellow eye to

reduce eye movements. Refer or Medevac immediately.

PROGNOSIS: Depends on extent of injury, but will generally

result in some impairment of vision and possibly loss of vision.

Appendix D-41
CL CONSIDERATIONS: Carefully remove contact lens from both eyes

unless it is overlying a laceration.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-PENETRATING INJURY TO THE EYE

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CONDITION: Penetrating injury to the eye

STRUCTURES INVOLVED: Anterior Segment

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Severe pain, anxiety, blurred vision

HALLMARK SIGNS: Consistent History

OTHER SIGNS: Dark pigment showing through sclera indicates

scleral laceration with uveal prolapse, irregular shape to eye and cornea, contusions and lacerations to adenexa, generally little or no bleeding from eye, reduced visual acuity.

DIAGNOSTIC PROCEDURES:

TREATMENT: 1. If possible, do not remove projectile from eye if

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Appendix D-42
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it is still present. 2. apply sterile dressing over eye without pressure. 3.

If practical, place eye shield over bony orbit area to prevent further injury to the eye. 4. Patch fellow eye to reduce eye movement. 5.

Medevac or refer immediately.

PROGNOSIS: Depending on the extent of the injury and the

availability of adequate treatment, may result in minimal scarring and

little vision loss to complete loss of the eye and severe scarring of the

adenexa.

CL CONSIDERATIONS: If practical, remove contact lens from injured

eye, but be extremely cautious (do not exert any pressure on the eye).

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source:

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-- ORBITAL BLOWOUT FRACTURE

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CONDITION: Orbital Blowout Fracture

STRUCTURES INVOLVED: Orbit, eye

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS: ""diplopia"", especially on upgaze, following trauma to orbit and eye.

OTHER SYMPTOMS: Pain, Pain on eye movement,

Appendix D-43
HALLMARK SIGNS: History of trauma.

OTHER SIGNS: Enophthalmos, Orbital ""edema"", Ecchymosis, infraorbital

anesthesia.

DIAGNOSTIC PROCEDURES:

TREATMENT: 1. Broad Spectrum oral antibiotic (Keflex), 2. Oral

analgesic prn, 3. cold compress for 24 hours followed thereafter

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by warm, 4. Warn patient to not blow his nose. 5. Refer or

Medevac immediately.

PROGNOSIS: Varies greatly, depending on severity and degree of

ocular involvement, and rapidity of ophthalmological treatment.

CL CONSIDERATIONS: Remove contact lenses.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- RETINAL DETACHMENT

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CONDITION: Retinal Detachment

Appendix D-44
CONDITION: Retinal Detachment

STRUCTURES INVOLVED: Retina, Vitreous

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS: Gray curtain came up over my vision

OTHER SYMPTOMS: ""Flashing lights"A, ""metamophopsia"",

blurred vision, vitreous ""floaters"".

HALLMARK SIGNS: Tear or detachment of retina sometimes visible

by ophthalmoscopy

OTHER SIGNS: Reduced visual acuity, high ""myopia"A, history of

trauma, Visual field defects.

DIAGNOSTIC PROCEDURES: 1. Ophthalmoscopic examination may

reveal tear or detachment of retina, but detachments usually occur

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peripherally and are therefore difficult to see with the directophthalmoscope, even by an experienced examiner. 2. Confrontation visual

fields may reveal a visual field defect (usually inferior visual field). 3.

Vitreous humor may appear cloudy and debris laden on ophthalmoscopy.

TREATMENT: 1. Bed rest, patient should be essentially immobilized

in supine position without a pillow. 2. Refer or medevac immediately.

PROGNOSIS: 1. Depending on extent of detachment and

availability of definitive treatment, may cause little loss of vision or may

cause total blindness.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Appendix D-45
Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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-- SUBLUXATION OF THE LENS

-SAMEAS DISLOCATION OF THE LENS -- DISLOCATION OF THE LENS

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CONDITION: Subluxation or dislocation of the lens

STRUCTURES INVOLVED: Lens, iris, ""anterior chamber"", vitreous

cham- ber

LATERALITY: Usually unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Blurred vision, monocular ""diplopia"", pain

particularly if associated with trauma.

HALLMARK SIGNS: Aboard Submarine, will generally be secondary

to trauma.

OTHER SIGNS: Irregular shallowing of Anterior Chamber, dislocated

lens may be visible through large (dilated) pupil, iris tremors especially

with eye movement, reduced visual acuity.

DIAGNOSTIC PROCEDURES:

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Appendix D-46
TREATMENT: Refer or medevac for definitive treatment immediately

PROGNOSIS:

CL CONSIDERATIONS:

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

-- BACTERIAL CONJUNCTIVITIS

-BACKGROUND BLUE

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CONDITION: Bacterial Conjunctivitis

STRUCTURES INVOLVED: ""Conjunctiva"", Cornea, lids

LATERALITY: Usually begins unilateral then becomes bilateral

HALLMARK SYMPTOMS: Mucous and ""purulent"" ""discharge""

(""mucopurulent"") with lid matting in AM

OTHER SYMPTOMS: Usually no pain, scratchy sensation when blinking, slightly blurred vision.

HALLMARK SIGNS: Mucopurulent ""exudate""

OTHER SIGNS: Conjunctivai injection, slight chemosis,

mucopurulent discharge, slightly reduced visual acuity

DIAGNOSTIC PROCEDURES: 1. ""Gram's Stain"" and ""Wright's

Stain"" will help confirm bacterial etiology. 2. Culture and sensitivity if

available.

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Appendix D-47
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TREATMENT: Topical antibiotic solution (sulfacetamide ophthalmic

solution, 2 drops in affected eye(s) qid until condition is resolved. If a

copious ""purulent"" discharge is present, a Neisseria Gonorrhoeae infection must be considered). Instruct patient regarding proper hygiene

to avoid spreading the disease to the fellow eye or to other crewmembers.

PROGNOSIS: Have pt return q 24h until resolved. Condition should

improve within 24 to 48 hours after onset of treatment and should

abate in about one week. A poor clinical response within 48-72 hours

indicates that either the bacterium is insensitive to the antibiotic or the

cause is not bacterial.

CL CONSIDERATIONS: Discontinue contact lens wear. As the contact lens may act as a repository for the bacterial agent, the patient

should not resume lens wear until directed by higher authority. Do not

assume that chemical lens disinfection will eliminate the pathogen.

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Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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MEDIC Hypertext Help System

-- VIRAL CONJUNCTIVITIS

-BACKGROUND BLUE

-CLS

-BACKGROUND BLUE

-COLOR WHITE

Appendix D-48
CONDITION: Viral Conjunctivitis

STRUCTURES INVOLVED: ""Conjunctiva"", Cornea

LATERALITY: Usually starts unilateral then becomes bilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: ""Weeping"", scratchy sensation, slightly

blurred vi- sion, ""photophobia"".

HALLMARK SIGNS: Above sx. accompanied by preauricular

adenopathy is indicative of a viral etiology. Above sx with cervical

adenopathy and pharyngitis is indicative of acute pharyngoconjunctival fever, also viral.

OTHER SIGNS: Watery discharge, little or no ""purulent"" or

""mucoid"" ""discharge"", conjunctival injection, chemosis, patchy

corneal epithelial defects may be seen with staining, reduced visual

acuity.

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MEDIC Hypertext Help System

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DIAGNOSTIC PROCEDURES: Fluorescein stain may reveal corneal

involvement which is often present in viral conjunctivitis caused by the

adenoviruses.

TREATMENT: Generally, viral conjunctivitis is self limited, and requires no specific treatment. Vasoconstrictors may help alleviate

symptoms. Sulfacetamide may be prescribed to help prevent secondary bacterial infection.

PROGNOSIS: Have pt return q 24h until resolved. Condition

should begin to improve within a week after onset and should

abate within about two or three weeks.

CL CONSIDERATIONS: Discontinue contact lens wear. As the contact lens may act as a repository for the virus, the patient should

Appendix D-49
not resume lens wear until directed by higher authority. Do not assume

that chemical lens disinfection will eliminate the pathogen.

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MEDIC Hypertext Help System

-PRESS ANY KEY

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Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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MEDIC Hypertext Help System

-- ALLERGIC CONJUNCTIVITIS

-BACKGROUND BLUE

-CLS

-BACKGROUND BLUE

-COLOR WHITE

CONDITION: Allergic Conjunctivitis

STRUCTURES INVOLVED: ""Conjunctiva"", Lids

LATERALITY: Usually Bilateral

HALLMARK SYMPTOMS: Itching, usually severe

OTHER SYMPTOMS: Stringy ""discharge"", ""weeping"".

HALLMARK SIGNS: Generalized swelling e.g. Conjunctival ""^edema"" (chemosis), lid edema.

OTHER SIGNS: History of allergic conditions (Hay Fever), minimal

stringy, white discharge may be present, conjunctival concretions

may be present in chronic cases.

Appendix D-50
DIAGNOSTIC PROCEDURES: ""Wright's stain"" of conjunctival

scraping may reveal increased ""eosinophils"" indicating a allergic

response.

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MEDIC Hypertext Help System

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TREATMENT: Environmental comforters, vasoconstrictors, and cold

compresses may help alleviate some symptoms. Oral and topical

antihistamines may help. Instruct patient to avoid rubbing eyes. In

severe cases topical steroids may be used for very brief periods--be

extremely cautious with steroids.

PROGNOSIS: Usually self limited, seasonal and chronic

CL CONSIDERATIONS: Discontinue contact lens wear and refer for

evaluation of desirability of contact lens wear.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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MEDIC Hypertext Help System

-- CHALAZION

-BACKGROUND BLUE

-CLS

-BACKGROUND BLUE

-COLOR WHITE

CONDITION: Chalazion

STRUCTURES INVOLVED: Upper lid

LATERALITY: Usually Unilateral

Appendix D-51
HALLMARK SYMPTOMS: Hard lump in upper lid which grows very

slowly.

OTHER SYMPTOMS: Blurred vision, irritation.

HALLMARK SIGNS:

OTHER SIGNS: Indurated mass in upper lid which is usually oblong

with the long axis running vertically, Possible palpebral conjunctival injection and chemosis but generally little acute inflammatory response,

slightly reduced acuity.

DIAGNOSTIC PROCEDURES: Palpate the lesion, if not painful and

mass is felt to be internal, it probably is a chalazion.

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MEDIC Hypertext Help System

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TREATMENT: Hot compress to affected area for 20 minutes qid for 4

days to soften material and hasten expulsion. If mass remains

after treatment, refer at first convenience for surgical removal.

PROGNOSIS: A true chalazion is a lipogranuloma of one of the

meibomian glands which probably will not respond to treatment

with hot compresses. A hordeolum, which is an acute inflammation

will either respond to hot compress treatment by draining or may become granulomatous thereby developing into a chalazion.

CL CONSIDERATIONS: In general, discontinue contact lens wear

while under treatment. If the patient is wearing soft contact lenses and

the chalazion is not interfering with lens, he may continue to wear the

lens. Hard or gas permeable lenses should be discontinued until the

condition is fully resolved.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Con-

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-COLOR CYAN

Appendix D-52
-CURSET 1,5

MEDIC Hypertext Help System

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cepts. 4th ed. St Louis: CV Mosby, 1978.

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MEDIC Hypertext Help System

-- HORDEOLUM

-BACKGROUND BLUE

-CLS

-BACKGROUND BLUE

-COLOR WHITE

CONDITION: Hordeolum

STRUCTURES INVOLVED: Lid, upper or lower

LATERALITY: Usually Unilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Pain, tenderness, lump in eyelid,

HALLMARK SIGNS:

OTHER SIGNS: Red, ""indurated"" mass in upper or lower eyelid,

usually at the lid margin. The lesion usually produces pus.

DIAGNOSTIC PROCEDURES: Palpate the lesion, if tender and mass

is felt to be near the lid margin, it probably is a hordeolum.

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MEDIC Hypertext Help System

-PRESS ANY KEY

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Appendix D-53
TREATMENT: Hot compress for 20 minutes qid for 4 days. A hordeolum will usually drain within this time period. Topical antibiotics may be administered (sulfacetamide 10% 2 drops qid) to

prevent spread of infection to adjacent glands or follicles.

PROGNOSIS: Usually will respond to treatment within 96 hours.

If not, consider differential diagnosis with ""chalazion"" and refer

as necessary.

CL CONSIDERATIONS: Discontinue contact lens wear until condition

is resolved.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source:

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MEDIC Hypertext Help System

-- BLEPHARITIS

-BACKGROUND BLUE

-CLS

-BACKGROUND BLUE

-COLOR WHITE

CONDITION: Blepharitis

STRUCTURES INVOLVED: Lid, upper and lower, ""conjunctiva""

LATERALITY: Usually bilateral

HALLMARK SYMPTOMS:

OTHER SYMPTOMS: Chronic irritation, itching, burning, scaling

HALLMARK SIGNS: Exfoliation of skin along margins of lids, particularly upper lids.

OTHER SIGNS: Redness of lid margins, possibly accompanied with

slight lid edema. Loss of eye lashes, white eye lashes. Usually associated with dandruff or seborrhea of the scalp.

Appendix D-54
DIAGNOSTIC PROCEDURES:

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MEDIC Hypertext Help System

-PRESS ANY KEY

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TREATMENT: Lid scrubs with cotton tipped applicator and diluted

mild (baby) shampoo. In more severe cases, sulfacetamide solution or ointment may be applied to the lid margins bid. Dandruff

shampoo for scalp, if indicated.

PROGNOSIS: This is a chronic condition that is almost never

cured. When convenient, refer troublesome cases.

CL CONSIDERATIONS: A contact lens may exacerbate the symptoms

of this condition. If the condition is moderate to severe, the patient

should not wear lenses.

Primary Source: Training Manual for Independent Duty Submarine

Corpsmen

Secondary Source: Newell FW. Ophthalmology, Principles and Concepts. 4th ed. St Louis: CV Mosby, 1978.

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MEDIC Hypertext Help System

-- TRIGEMINAL

-IMAGE(TRIGEMV2.PCX -K'\N' -Ml 8)

-BACKGROUND BLUE

-CLS

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TRIGEMINAL

Because the cornea has so many sensory inputs to the

trigeminal nerve, it is extremely sensitive to pain. Thus,

whenever a patient complains of pain, scratchiness, or irritation, a careful examination of the cornea is indicated.

Appendix D-55
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MEDIC Hypertext Help System

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IRRITATION

While patients often complain that their eyes feel

"irritated," a more descriptive complaint is needed by the

program to help make a diagnosis. Most patients can

define irritation more accurately if encouraged by the examiner. Ask them what they mean by irritation: pain; itching; a scratchy sensation; tiredness; etc.

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MEDIC Hypertext Help System

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-BACKGROUND BLUE

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Visual Disturbance

DEFINITION: An interference with the ability to see

normally, including ""blurred vision"", ""diplopia"", and

""photopsia"".

BACKGROUND: A visual disturbance symptom usually

indicates a problem with the ocular media (cornea, lens,

aqueous and vitreous humor) or with the neural elements

of the eye and visual pathway (retina, optic nerve, and

higher visual centers). For more information on specific

types of visual disturbance, see the help screens on

""^double vision"A, ""distorted vision"", ""flashing

lights"", ""floaters"", and ""halos around lightsA".

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Appendix D-56
-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,9,70, CYAN

-BORDER 11,10,20,70, CYAN

-- blurred vision

-SAMEAS decreased vision

-- decreased vision

-SAMEAS blurred or decreased vision

-- blurred or decreased vision

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Blurred or Decreased Vision

DEFINITION: An interference with the ability to see

fine detail such as small print. Details become "fuzzy"

and difficult to resolve.

BACKGROUND: Blurred vision can be either constant

or intermittent. Constant blurring of the vision is usually

caused by uncorrected or undercorrected ""refractive

error"", but can also be caused by disturbances in the

ocular media such as reduced clarity of the lens or cornea. Intermittent blurred vision can be caused by exudative material in the tear film, fatigue of the visual system,

and sometimes vascular or neurologic abnormalities.

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MEDIC Hypertext Help System

-BORDER 5,10,9,70, CYAN

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-- double vision

-SAMEAS diplopia

-- diplopia

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-57
Double Vision

DEFINITION: Also known as diplopia, double vision is a

condition where one perceives two images of a single

object. Diplopia can be monocular or binocular.

BACKGROUND: In monocular diplopia, double vision

persists even when the uninvolved eye is occluded.

Common causes of monocular diplopia include: ""ref ractive error""; corneal opacity or irregularity; and cataract.

Less common causes include: ""dislocated natural

lens""; extra pupillary openings; and ""retinal detachment"". In binocular diplopia, double vision is eliminated

when either eye is occluded. It is commonly caused by

decompensated phorias, and sometimes by neurologic

abnormalities.

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MEDIC Hypertext Help System

-BORDER 5,10,9,70, CYAN

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-- distorted vision

-SAMEAS metamorphopsia

-- metamorphopsia

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Distorted Vision

DEFINITION: Also known as metamorphopsia, distorted

vision is a disorder where images appear distorted in

shape or size.

BACKGROUND: Metamorphopsia is most commonly

caused by ""refractive error"", retinal disease such as

central serous retinopathy, or corneal irregularities. Less

common causes include: cataract; topical eye drops,

especially miotics such as pilocarpine; migraine head

aches where the symptoms are transient; and central

nervous system abnormalities.

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Appendix D-58
MEDIC Hypertext Help System

-BORDER 5,10,9,70, CYAN

-BORDER 11,10,19,70, CYAN -- flashing lights

-SAMEAS photopsia

-- photopsia

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Flashes of light

DEFINITION: Also known as photopsia, flashes of light refers to the inappropriate perception of light flashes

or lightning bolts by the visual system.

BACKGROUND: Photopsia is most commonly caused

by ""retinal breaks or detachments"", ""vitreous detachment"", migraine syndrome, or rapid eye movement

(especially in darkness). Less common causes include

disorders of the central nervous system and active retinal

pathology.

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MEDIC Hypertext Help System

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-- floaters

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Floaters

DEFINITION: Also known as muscae volitantes (Latin

for flitting flies), floaters are perceived as spots or specks

floating before the eyes.

BACKGROUND: -Floaters are usually caused by particles suspended in the normally clear vitreous humor.

They can be transient or long-standing. Long-standing

or permanent floaters may be caused by ""vitreous

detachment"", posterioruveitis, or vitreous hemorrhage.

Appendix D-59
Sometimes, long-standing or new vitreous floaters may

indicate ""retinal detachment"". Transient floaters may

occur with migraine syndrome.

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MEDIC Hypertext Help System

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-BORDER 11,10,19,70, CYAN -- halos

-SAMEAS halos around lights -- halos around lights

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Halos around lights

DEFINITION: Halos around lights refers to the perception of an abnormal ring of glare when one looks toward

a bright light source.

BACKGROUND: The perception of halos generally

arises from severe corneal ""edema"" or an opacity of

the natural lens. If corneal edema is the cause, it should

be visible to the examiner as a hazy or dull appearance

to the entire cornea. Generalized corneal edema can

occur with ""acute angle closure glaucoma"" or with a

number of less common corneal disorders.

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MEDIC Hypertext Help System

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-- associated history of ocular trauma

-SAMEAS trauma

-- trauma

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-60
History of trauma

DEFINITION: Ocular trauma, in the context of this program, refers to blunt or penetrating trauma to the eye,

orbit or head which you feel might be contributing to your

patient's current condition.

BACKGROUND: Blunt trauma may cause a number of

injuries to the eye including: ""traumatic iritis""; ""retinal

detachment"A; ""dislocation of the lens"A; comotio

retinae; ""hyphema""; and secondary glaucoma. In

cases of blunt ocular trauma, the examiner must be

watchful for signs and symptoms such as ""photopsia"", ""Ametamorphopsia"", ""floaters"", pupillary abnormalities, and ""diplopia"".

Press <ENTER> to continue

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History of trauma

BACKGROUND: Penetrating trauma where a foreign object actually penetrates or is suspected of penetrating the

eye will generally result in a medevac.

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MEDIC Hypertext Help System

-BORDER 7,10,11,70, CYAN -- high myopia ~ SAMEAS myopia

-- myopia

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-61
High Myopia

DEFINITION: High myopia is a condition where the axial

length of the eye is too long for the optics of the eye. For

the purposes of this program, high myopia is defined as

refractive error exceeding -3.00 diopters (e.g. -4.OOD).

For more discussion about the nature of myopia, see the

screen on ""refractive error"".

BACKGROUND: Because myopic eyes are generally

larger than average, their retinas tend to be stretched

compared to non-myopic eyes. This stretching of the

retina is thought to increase the likelihood of ""retinal

breaks"" and ""vitreous detachments"".

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MEDIC Hypertext Help System -BORDER 5,10,12,70, CYAN

-BORDER 13,10,19,70, CYAN -- high hyperopia

-SAMEAS hyperopia

-~hyperopia

-BACKGROUND BLUE

-CLS

-COLOR WHITE

High Hyperopia

DEFINITION: High hyperopia is a condition where the

axial length of the eye is too short for the optics of the

eye. For the purposes of this program, high hyperopia is

defined as refractive error exceeding +3.00 diopters (e.g.

+4.OOD). For more discussion about the nature of hyperopia, see the screen on ""refractive error"".

BACKGROUND: Because hyperopic eyes are generally

smaller than average, their anterior chamber angles tend

to be smaller than non-hyperopic eyes. Narrow chamber

angles are thought to increase the likelihood of

""acute angle closure glaucoma"".

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Appendix D-62
MEDIC Hypertext Help System

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-- indurated

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Indurated

DEFINITION: An abnormally hard spot or place. In the

context of this program, induration is only concerned with

hard or firm masses of the eyelids which might be indicative of a ""hordeolum"" or ""chalazion"".

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MEDIC Hypertext Help System

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-- erythema

-BACKGROUND BLUE

-CLS

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Erythema

DEFINITION: Indicates a flush on the skin caused by

congestion of the capillaries which may result from a

variety of causes. Erythema is one of the classical signs of ""inflammation"".

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MEDIC Hypertext Help System

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-- inflammation

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-63
Inflammation

DEFINITION: A localized protective process caused by

injury to tissues which serves to destroy, dilute, or wall

off both the injurious agent and the affected tissue.

BACKGROUND: The classical signs of inflammation include pain (dolor), ""redness"" (rubor), heat (calor), ""^swelling"" (tumor), and loss of function (functio laesa).

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-- chemosis

-SAMEAS edema -- swelling -SAMEAS edema

-- edema

"-BACKGROUND BLUE

"-CLS

-COLOR WHITE

Edema

DEFINITION: The presence of abnormally large

amounts of fluid in the intercellular tissue spaces of the

body. Edema of the ""conjunctiva"" is referred to as

chemosis.

BACKGROUND: Edema, one of the classical signs of

""^inflammation"", can occur in virtually all ocular tissues

from the lids to the retina. Generally, edema results in

visible swelling of the affected tissue throughout the eye

except for corneal edema which causes a grayish cast to

the normally clear cornea.

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MEDIC Hypertext Help System

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-- eczematous

Appendix D-64
-BACKGROUND BLUE

-CLS

-COLOR WHITE

Eczema

DEFINITION: Involving primarily the epidermis of the

eye lids, eczema is characterized by scaling, crusting,

redness, exudation, and swelling around the lid margins.

BACKGROUND: Eczematous flaking along the lid margins, which is indicative of ""blepharitis"", is a common

finding even in asymptomatic patients. In severe cases,

the ""conjunctiva"" and even the cornea can become involved. Be aware, however, that chronic blepharitis often

coexists with other more acute and more serious conditions.

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-- tender

-SAMEAS tenderness -- non-tender

-SAMEAS tenderness

-- tenderness

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Tenderness

DEFINITION: An abnormal painful sensation in

response to touch or pressure.

BACKGROUND: Tenderness is used by this program to

help differentiate between a ""chalazion"" and a ""hordeolum"". Because a hordeolum is generally an acute

inflammatory response to a blocked eyelid gland, it will

usually be painful or tender. A chalazion, which is a

generally a chronic condition, is usually non-tender and

not painful.

Appendix D-65
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MEDIC Hypertext Help System

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-- conjunctiva

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Conjunctiva

DEFINITION: A highly vascularized but normally

transparent membrane which lines the eyelids (palpebral

conjunctiva) and covers the exposed surface of the

sclera or white of the eye (bulbar conjunctiva).

BACKGROUND: Because it is part of the eye's front line

defense, the conjunctiva responds to virtually all eye

diseases affecting the anterior segment.

FOR MORE INFORMATION SELECT: ""Ocular

Anatomy Diagram"" ""Conjunctival Anatomy Diagram""

""ARedness"" ""Inflammation"^ ^"Papillae"" ""Edema""

""^Follicles""

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-- injection

-SAMEAS redness --~conjunctival redness

-SAMEAS redness

-- redness

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-66
Redness

DEFINITION: In the context of this program, redness

refers to any condition where the ""conjunctiva"" appears red or pink from any cause including dilation of

blood vessels (""erythema"") and ""subconjunctival

hemorrhage"".

BACKGROUND: If you indicate that the conjunctiva is

red, the program will ask you to further define the

location (""diffuse"", ""circumcorneal"", or ""sectorial"")

and severity of the redness.

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-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,10,70, CYAN

-BORDER 11,10,16,70, CYAN -- follicles

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Follicles

DEFINITION: Conjunctival follicles are small (0.5

to 1 mm), yellow-white elevations of lymphoid tissue

that generally occur in the ""fornix conjunctiva"".

BACKGROUND: Unless a follicular response is severe,

it will probably be invisible to the naked eye. It is

important to differentiate follicles from ""papillae"". Conjunctival follicles usually indicate an acute viral infection.

-BORDER 2,2,22,78, CYAN

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-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,9,70, CYAN

-BORDER 11,10,17,70, CYAN

-- papillae

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-67
Papillae

DEFINITION: Conjunctival papillae are usually small

(0.1 to 0.2mm), red elevations of vascular tissue

that generally occur in the ""tarsal conjunctiva"".

BACKGROUND: Unless a papillary response is severe,

it will probably be invisible to the naked eye, although

papillae can be quite large in exaggerated responses.

Fluorescein dye can be used to accentuate the appearance of papillae. It is important to differentiate papil- lae from ""follicles"". Conjunctival papillae usually

indicate an allergic reaction or a bacterial infection.

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MEDIC Hypertext Help System

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-- diffuse

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Diffuse

DEFINITION: Diffuse refers to the property of being

widely spread or scattered.

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MEDIC Hypertext Help System

-BORDER 5,10,8,70, CYAN

-- circumcorneal

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Circumcorneal Injection

DEFINITION: Circumcorneal injection is a condition

where blood vessels adjacent to the cornea become

congested, forming a ring of injection around the

cornea.

Appendix D-68
BACKGROUND: Circumcorneal injection is generally indicative of ""inflammation"" of the iris or cornea.

It usually occurs in conditions like iritis or ""acute angle

closure glaucoma"".

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MEDIC Hypertext Help System

-BORDER 5,10,10,70, CYAN

-BORDER 11,10,16,70, CYAN -- sectorial

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Sectorial

DEFINITION: In the context of this program, sectorial

""^redness"" refers to injection or pooling of blood that is

limited to only a part of the ""conjunctiva"".

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-SAMEAS fornix conjunctiva

-- fornix

-SAMEAS fornix conjunctiva -- fornix conjunctiva

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Fornix Conjunctiva

DEFINITION: The fornicies of the ""conjunctiva"" are

the areas where the conjunctiva reflects back from the

globe to the lids forming pockets above and below the

eye.

BACKGROUND: The conjunctival fornicies prevent

foreign bodies and contact lenses from dislodging behind

Appendix D-69
the Anatomy eye. For Diagram^^. more information, see ^^Conjunctival

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-- weeping

-SAMEAS excessive tearing

-- excessive tearing

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Excessive Tearing

DEFINITION: Excessive tearing, also known as weeping

or epiphora, is caused by excessive production of tears

by the lacrimal gland, usually in response to corneal

stimulation.

BACKGROUND: Excessive tearing usually occurs with

problems that affect the cornea, conjunctiva, or both. It

is fairly common with ^^corneal abrasion^As, viral and allergic conditions, but can also occur with blockage of the

tear drainage apparatus.

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-- stringy

-BACKGROUND BLUE

-CLS

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Stringy Discharge

DEFINITION: A stringy or ropey **dischargeA* is usually

found in the inferior **conjunctival fornix*^. It is usually
white or yellow in color and appears like strands of string

running parallel to the fold of the AAconjunctivaAA.

BACKGROUND: A stingy discharge is generally indicative of AAallergic conjunctivitis^* but may occasionally

occur with AAviral conjunctivitisAA.

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-BORDER 11,10,15,70, CYAN -- mucoid

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Mucoid Discharge

DEFINITION: A mucoid AAdischargeAA is usually found

in the inferior AAconjunctivaAA. It is yellowish in color and

has a consistency similar to honey.

BACKGROUND: A mucoid discharge without

AApurulenceAA is generally indicative of AAviral conjunctivitisA* but may occasionally occur with AAbacterial

conjunctivitis*^.

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-BACKGROUND BLUE

-CLS

-COLOR WHITE

Mucopurulent Discharge

DEFINITION: A mucopurulent AAdischargeAA is usually

found in the inferior ^^conjunctiva^^. It is yellow to white

Appendix D-71
in color and is a combination of ""mucoid"" and

"^Apurulent"" material.

BACKGROUND: A mucopurulent discharge is generally

indicative of ""bacterial conjunctivitis"".

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-- purulent

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Purulent Discharge

DEFINITION: A purulent ""discharge"" is usually found

in the inferior ""conjunctiva^". It is white or creme

colored and is a composed primarily of white blood

cells.

BACKGROUND: A purulent discharge is generally

indicative of ""bacterial conjunctivitis"". If a great

deal of purulence is present, be sure to consider

""Ahyperacute conjunctivitis"" (gonococcal).

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-- intraocular pressure

-BACKGROUND BLUE

-CLS

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Intraocular Pressure

DEFINITION: The globe is filled with fluids which cause

an intraocular pressure (lOP) which is greater than theatmospheric pressure. The pressure is produced by

Appendix D-72
aqueous production by the ciliary body which exceeds

aqueous outflow.

BACKGROUND: Normal lOP is between 7 and 22

mmHG. High lOP may be indicative of ""acute angle

closure glaucoma"". Sometimes lOP may be low in an

eye suffering from iritis. If you need instructions on the

""*Schiotz tonometer"A, use

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-- tactile tensions

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Tactile Tensions

DEFINITION: Tactile tension measurement is a method

of estimating the ""intraocular pressure"" of the eyes by

pressing with your thumbs on the patient's closed eyes.

METHOD: Have your patient look downward and close

his eyes. Then press firmly (not excessively) on his

upper eyelids with your thumbs. Do both eyes at the

same time. The real value of this test is in determining whether one eye has a significantly different pressure than its fellow.

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-BACKGROUND BLUE

-CLS

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Appendix D-73
Visual Fields

To measure visual fields, seat yourself directly across

from your patient. Be sure that both of your heads

are at the same height and that you are about one meter

apart. Have your patient close or cover his left eye

first. Then close your right eye. Instruct your

patient to look directly into your open (left) eye at

all times. This insures accurate fixation. Next, hold

your hands between yourself and your patient such that

your hands are 0.5 meters from you and 0.5 meters from

your patient. Then hold up one or two fingers on each

hand and ask your patient how many fingers he sees.

Check the patient's visual field in all directions. Use your

own visual field as a check to determine whether your

patient's visual field is normal. Then repeat for the fellow

eye.

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-- general constriction of visual field

-BACKGROUND BLUE

-CLS

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Constriction of the Visual Field

DEFINITION: A general constriction of the visual field

of an eye occurs when the field is reduced in more or

less all directions.

BACKGROUND: A generalized constriction of the visual

field may be indicative of one of the glaucomas but can

also occur with retinitis pigmentosa, chronic papilledema,

central retinal artery occlusion with macular sparing,

and other conditions.

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-- sectorial defect

-BACKGROUND BLUE

Appendix D-74
-CLS

-COLOR WHITE

Sectorial Field Defect

DEFINITION: A sectorial field defect, also known as an

altitudinal field defect, is characterized by a blind

area in a part or sector of the visual field.

BACKGROUND: A sectorial field defect may occur with

""^retinal detachment"", ischemic optic neuropathy,

branch artery or vein occlusion, or less commonly with

glaucoma, optic nerve or chiasmal lesions, and optic

nerve coloboma.

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-- pre-auricular nodes

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Pre-Auricular Nodes

DEFINITION: The pre-auricular lymph nodes are located

on either side of the face about one centimeter anterior

and one centimeter below the ear lobe.

METHOD: Palpate the nodes with your fingers to see if

they are enlarged (palpable). Ask your patient if he

senses any tenderness while you apply light pressure to

the nodes. Appropriate findings for the chart include

normal, ""palpable and tender"", and ""palpable and

non-tender"".

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Appendix D-75
-- palpable and non-tender

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Palpable and Non-Tender Nodes

DEFINITION: Palpable and non-tender nodes are enlarged (palpable) ""pre-auricular nodes"" that are not

sensitive to touch (non-tender).

BACKGROUND: When the pre-auricular nodes are enlarged but non-tender, the following conditions may be indicated: pharyngoconjunctival fever, chlamydial conjunctivitis, Newcastle conjunctivitis or an infection by enterovirus 70.

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-BORDER 11,10,17,70, CYAN -- palpable and tender

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Palpable and Tender Nodes

DEFINITION: Palpable and tender nodes are enlarged

(palpable) ""pre-auricular nodes"" that are sensitive

to touch (tender).

BACKGROUND: When the pre-auricular nodes are enlarged and tender, a number of conditions may be indicated: epidemic keratoconjunctivitis, ""herpes keratitis""

preseptal cellulitis, or one of the infectious

granulomatous diseases.

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Appendix D-76
-BORDER 11,10,17,70, CYAN

-- localized edematous area

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Localized Corneal Edema

DEFINITION: Localized corneal ""edema"" is characterized by a white or grayish patch in the cornea with fuzzy, ""diffuse"" borders. Without a microscope,

edema may be difficult to distinguish from ""infiltrates"".

BACKGROUND: Localized corneal edema may be indicative of a severe ""corneal abrasion"", a ""corneal

foreign body"", or a corneal ulcer. It generally indicates

that the cornea has been compromised fairly severely,

so the patient should be followed carefully.

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-BORDER 11,10,17,70, CYAN -- infiltrate

-SAMEAS infiltrates -- infiltrates

-IMAGE(INFILTV.PCX -KN' -Ml 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Corneal Infiltrates

DEFINITION: Corneal infiltrate(s) are collections of white

blood cells in the deeper layers of the cornea. They look

like white or grayish spot(s) with well defined borders.

Without a microscope, infiltrates may be difficult to

distinguish from ""localized comeal edema"A.

BACKGROUND: A corneal infiltrate visible to the naked

eye or with a hand magnifier would generally indicate a

corneal ulcer. Microscopic infiltrates occur with some

Appendix D-77
viral conditions such as epidemic keratoconjunctivitis and

may also result from long term contact lens wear.

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-- discharge

-SAMEAS exudate -- exudate

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Discharge (Exudate)

DEFINITION: A discharge or exudate is material, such

as fluid, cells, or cellular debris, which has escaped from blood vessels and has been deposited in tissues

or on tissue surfaces, usually as a result of ""inflammation"".

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-CURSET 2, 5

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~-gram's stain

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Gram's Stain

DEFINITION: An empirical staining procedure

developed by Gram in which microorganisms are stained

with crystal violet. Organisms that retain the stain are

said to be Gram positive, and those that do not retain the

stain are said to be Gram negative.

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--Color CYAN

-CURSET 2, 5

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Appendix D-78
-BORDER 5,10,11,70, CYAN

-- wright's stain

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Wright's Stain

DEFINITION: A mixture of eosin and methylene blue

used for demonstrating blood corpuscles and malarial

parsites.

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-CURSET 2, 5

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-BORDER 5,10,8,70, CYAN -- fluorescein

-SAMEAS fluorescein staining -- fluorescein staining

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Fluorescein

DEFINITION: Fluorescein is a soluble orange dye which

can be used to reveal corneal lesions in the eye. It

appears bright green under ultra violet light.

BACKGROUND: Fluorescein dye should be used whenever corneal involvement is suspected. When viewing a

staining pattern, be sure to have your patient blink frequently; mucous globules stain readily, but they will

move with blinking, allowing you to distinguish them from

true corneal staining. Fluorescein staining of the conjunctiva is generally of little importance.

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-CURSET 2, 5

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-BORDER 11,10,19,70, CYAN -- contact lens care solutions

Appendix D-79
-BACKGROUND BLUE

-CLS

-COLOR WHITE

Contact Lens Solutions

DEFINITION: A variety of contact lens care products

are available. They fall into five general classes:

(1) daily cleaning solutions; (2) weekly (usually enzyme)

cleaning products; (3) Disinfecting solutions; (4) rinsing

solutions (saline); and (5) rewetting solutions.

BACKGROUND: At a minimum, every contact lens

wearer should be using a daily cleaning solution and a

disinfecting solution every time they remove a lens from

their eyes.

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-BORDER 13,10,18,70, CYAN -- preservatives

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Solution Preservatives

DEFINITION: Most contact lens care solutions contain

one or more agents that function as preservatives to inhibit growth of microorganisms.

BACKGROUND: Some preservatives are frequently implicated in cases of contact lens ""solution allergyA" or

sensitivity. They are: chlorhexidine, thymerosol, and the

sorbic acid group. They have generally been replaced

by less troublesome preservatives, but the older solutions are still available and in use by some patients.

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-CURSET 2, 5

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Appendix D-80
-BORDER 5,10,9,70, CYAN

-BORDER 11,10,18,70, CYAN -- contact lens deposits

-SAMEAS deposits

-- deposits

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Contact Lens Deposits

DEFINITION: A number of materials can deposit on the

surface of a contact lens. Protein is the most common,

but lipids and minerals are also often present.

BACKGROUND: Protein deposits will give the lens a

hazy appearance under white light and magnification.

Lipid deposits sometimes look like bumps of clear jelly

on the surface of the lens. Mineral deposits usually appear to be hard white spots on the lens surface. The

best way to deal with lens deposits is to replace the lens.

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-- damaged edge

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Damaged Contact Lens Edge

DEFINITION: Soft contact lenses are susceptible to

edge tears which are visible under ""careful examination"". An edge tear generally causes vague symptoms

of discomfort.

BACKGROUND: A damaged contact lens edge is diagnosed by direct examination of the contact lens. If an

edge irregularity is detected, the only solution is to

replace the contact lens or to discontinue contact lens

Appendix D-81
wear until a replacement contact lens is available. The

patient should be instructed in proper handling methods.

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-- inverted lens

-BACKGROUND BLUE

"-CLS

-COLOR WHITE

Inverted Contact Lens

DEFINITION: Soft contact lenses can be turned inside

out. ""Careful examination"" of the lens will reveal an

inverted lens as the edges will flare slightly outward.

BACKGROUND: An inverted contact lens is diagnosed

by direct examination of the contact lens. If a lens

is inverted, it may move excessively on the eye causing

slightly blurred vision and mild discomfort. Usually,

one can simply reinvert the lens and return to normal

lens wear if no other problems are present.

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-CURSET 2, 5

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"--anterior chamber

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Anterior Chamber

DEFINITION: The anterior chamber is the space

bounded by the iris, posteriorly, and the cornea anteriorly. It is filled with ""aqueous humor"". For more information, see the ""ocular anatomy diagram"".

-BORDER 2,2,22,78, CYAN

Appendix D-82
-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

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-- aqueous humor

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Aqueous Humor

DEFINITION: Aqueous humor fills the ""anterior chamber"". It is constantly produced by the ciliary body and

drained by the aqueous outflow apparatus.

BACKGROUND: In some internal eye infections, such

as iritis, the normally clear aqueous humor can become

somewhat cloudy, as white blood cells and blood

proteins escape from blood vessels with ""inflammation" . Also, ""acute angle closure glaucoma"" can

result if the aqueous outflow apparatus is blocked.

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-- subluxated lens

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Subluxated Lens

DEFINITION: Also known as a dislocated lens, a

subluxated lens is a displaced crystalline lens that

at least partially remains within pupillary opening.

BACKGROUND: Trauma is the most common cause of

a subluxated lens, but lens dislocation can occur with

some rare systemic conditions, such as Marfan's

syndrome. Usually, the patient would complain of

monocular ""diplopia"". Any case of subluxation

Appendix D-83
should be treated like ""retinal detachment"" and

medevaced immediately.

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-BACKGROUND BLUE

-CLS

-COLOR WHITE

Vitreous Detachment

DEFINITION: Vitreous body separated from its normal

attachments, due to shrinkage from degenerative or inflammatory conditions, trauma, ""myopia"", or senility.

BACKGROUND: While a vitreous detachment is generally a benign condition, there is no way to differentiate

a vitreous detachment from aAAretinal detachment"" with

the equipment available on a submarine. Thus, all cases

of vitreous detachment should be treated as though they

are ""retinal detachmentA"s and medevaced immediately.

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-- onset

-BACKGROUND BLUE

-CLS

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Onset

DEFINITION: Onset refers to the characteristics of the

beginning of symptomology.

Appendix D-84
BACKGROUND: Sudden onset implies that symptomology began and developed abruptly, over a time course of

hours, not days. Acute onset means that symptoms

developed over a period of several hours to several

days. A chronic onset occurs when symptoms have

developed very slowly or when the condition has been

present for a long time.

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-BORDER 11,10,19,70, CYAN -- Test for corneal anesthesia

-SAMEAS comeal sensitivity test

-- corneal sensitivity measurement

-SAMEAS comeal sensitivity test

-- corneal sensitivity test

-IMAGE(CORNSNSV.pcx -K'N' -Ml 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Corneal Sensitivity Test

REVIEW METHOD: To measure corneal sensitivity, make a cotton wisp from a cotton tipped applicator by

pulling some of the cotton swab from each of two applicators. The goal is to create two applicators each with

a single fiber of cotton extending from the tip.

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-PRESS ANY KEY

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Appendix D-85
Corneal Sensitivity Test

Next, have your patient look upward and lightly touch

the cotton wisp to the right inferior cornea and note your

patient's reaction. Repeat for the left eye using the

second applicator. With this test you are trying to

determine whether there is a significant difference in

corneal sensitivity between the two eyes.

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-- refractive error

-lmage(VISIONV.pcx -K'\N' -M1 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Refractive Error

A pinhole can be used to help differentiate blurred

vision caused by refractive error from blurring caused

by other factors. Make a 2mm hole in a piece of thin

cardboard with a pin or needle. Have the patient read

the eye chart while looking through the pinhole. If

his vision improves through the pinhole, then at least

some of the blurred vision is caused by under corrected

refractive error.

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-- neutrophils

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Neutrophils

DEFINITION: A granular leukocyte having a nucleus with

three to five lobes connected by slender threads of

chromatin, and cytoplasm containing fine inconspicuous

Appendix D-86
granules. Also known as polymorphonucleocytes

(PMN), polynuclear, or neutrophilic leukocytes.

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-CURSET 2, 5

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-BACKGROUND BLUE

-CLS

-COLOR WHITE

Eosinophils

DEFINITION: A granular leukocyte having a nucleus with

two lobes connected by a slender thread of chromatin,

and cytoplasm containing coarse, round granules that

are uniform in size.

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-CURSET 2, 5

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-BACKGROUND BLUE

-CLS

-COLOR WHITE

Lymphocytes

DEFINITION: A mononuclear leukocyte with a deeply

staining nucleus containing dense chromatin, and a

pale blue staining cytoplasm.

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-CURSET 2, 5

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~-monocytes

-BACKGROUND BLUE

-CLS

Appendix D-87
-COLOR WHITE

Monocytes

DEFINITION: A mononuclear phagocytic leukocyte with

an ovoid or kidney shaped nucleus containing lacey, linear chromatin, and abundant blue-gray cytoplasm filled with fine reddish granules.

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-CURSET 2, 5

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-- evert

-SAMEAS eversion

-- eyelid eversion

-SAMEAS eversion

-- eversion

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Lid Eversion

METHOD: Grasp the upper lashes and pull them away

from the globe. Next, apply pressure on the superior

part of the upper eyelid with a cotton tipped applicator

while flipping the inferior part of the lid over the applicator. Eversion can be maintained by light pressure

of the thumb over the lashes. The lid will return to

its normal position when the patient looks upward and

blinks his eyes.

Press <ENTER> for more

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-PRESS ANY KEY

-IMAGE(EversioV.pcx -K'N' -Ml 8)

-BACKGROUND BLUE

-CLS

Appendix D-88
-COLOR WHITE

Lid Eversion

BACKGROUND: Eyelid eversion is indicated in cases of

suspected foreign bodies, "lost" contact lenses, and with

certain anterior segment infections.

"-BORDER 2,2,22,78, CYAN

-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

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-IMAGE(dendritV.pcx -K'\N' -Ml 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Dendritic Keratitis

BACKGROUND: Dendritic keratitis nearly always indicates Herpes simplex keratitis. Some other conditions

can produce dendritic corneal lesions, however. These

include: Herpes zoster virus, recurrent corneal erosion,

and contact lens related pseudodendrites.

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MEDIC Hypertext Help System

-BORDER 5,10,11,70, CYAN -- tarsal

-SAMEAS palpebral conjunctiva

-- tarsal conjunctiva

-SAMEAS palpebral conjunctiva -- palpebral conjunctiva

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Palpebral Conjunctiva

DEFINITION: The palpebral or tarsal ""conjunctiva"" is

that part of the conjunctiva that lines the inner surfaces

Appendix D-89
of the eyelids. To examine the superior tarsal conjunctiva, you must ""evert"^ the eyelids.

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-- bulbar

-SAMEAS bulbar conjunctiva

-- bulbar conjunctiva

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Bulbar Conjunctiva

DEFINITION: The bulbar ""conjunctiva"" is that part of

the conjunctiva that covers the front of the globe or white

of the eye.

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-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

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-- foreign body tracking

-IMAGE(FBTRACKV.PCX -K"\N' -M1 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Foreign Body Tracking Stain

BACKGROUND: A AAfluoresceinAA staining pattern that

looks like a zig-zag line on the cornea is indicative

of a foreign body trapped on the inside surface of the

upper lid. Such a finding necessitates ""eyelid eversion"" to help rule out a foreign body.

-BORDER 2,2,22,78, CYAN

-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,11,70, CYAN

Appendix D-90
-- inspect the lenses

-SAMEAS contact lens examination

-- Carefully examine both contact lenses

-SAMEAS contact lens examination

-- careful examination

-SAMEAS contact lens examination

-- contact lens examination

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Contact Lens Examination

METHOD: With the equipment available on a submarine,

a contact lens examination can only be done with the

lens removed from the eye. Always begin with the right

lens first, and follow with the left lens to avoid mixing

the lenses. Place the right lens on your fingertip and

view it from various angles through the magnifier of the

Wood's lamp (if available). Examine the edges carefully

for irregularities or tears. Also look at the contour

of the lens edge to help determine if the lens is rightside-out. Next, look carefully at the front and back

surfaces of the lens. Look for deposits and surface

irregularities. Repeat the process for the left lens.

-BORDER 2,2,22,78, CYAN

-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,18,70, CYAN -- Ocular Anatomy Diagram

-IMAGE(ANATOMYV.PCX -K'\N' -Ml 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Press <Esc> to return to program

-BORDER 2,2,22,78, CYAN

-Color CYAN

Appendix D-91
-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,12,70, CYAN -- Conjunctival Anatomy Diagram

-IMAGE(CONJV.PCX -K'N' -Ml 8)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Press <Esc> to return to program

-BORDER 2,2,22,78, CYAN

-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System -BORDER 5,10,12,70, CYAN

-- Schiotz tonometer

-IMAGE(SCHIOTZV.PCX -K'\N' -M18)

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Schiotz Tonometry METHOD: Have your patient lay down comfortably on

his back. Instill one or two drops of local anesthetic in

each eye. While the anesthetic is taking effect (about

1 minute), prepare the tonometer: Place the 7.5 gm

weight on the plunger and ensure that the instrument is

sterile. Hold your patients eyelids open with one hand

and carefully lower the tonometer plunger-plate onto the

eye until the needle stabilizes. Use the table provided with the tonometer to convert the scale reading to a

pressure reading in mmHg. Alternatively, you can use

the ""Schiotz Conversion Table"" available by pressing

<F1 > and <Enter>.

-BORDER 2,2,22,78, CYAN

-Color CYAN

-CURSET 2, 5

MEDIC Hypertext Help System

-BORDER 5,10,18,70, CYAN

Appendix D-92
-- Schiotz Conversion Table

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Schiotz Convers

for 7.5 gm.

Scale Reading

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

Continued

1ion Table

load

Pressure (mmHg)

59.1

54.2

49.8

45.8

42.1

38.8

35.8

33.0

30.4

28.0

25.8

23.8

21.9

20.1

-BORDER 1,2,22,78, CYAN

-Color CYAN

-CURSET 1, 5

MEDIC Hypertext Help System

-PRESS ANY KEY

-BACKGROUND BLUE

-CLS

-COLOR WHITE

Schiotz Conversion Table

for 7.5 gm. load

Scale Reading Pressure (mmHg)

7.0 18.5

7.5 17.0

8.0 15.6

8.5 14.3

9.0 13.1

9.5 12.0

10.0 10.9

Appendix D-93
10.5 10.0

11.0 9.0

11.5 8.3

12.0 7.5

12.5 6.8

13.0 6.2

-BORDER 1,2,22,78, CYAN

-Color CYAN

-CURSET 1, 5

MEDIC Hypertext Help System

Appendix D-94
Appendix E

Shell Configure, Command, and Rule Files
SHELL.CFG File

FORWARD

NOBACKWARD

NOTITLE

SCR=RE7.SCR

NOQUESTIONS

QUIT=JUNK

QUITEXIT

SHELL.CMD File

ASK Q1

IF [X]O

EXIT

ENDIF

Appendix E-2
Subject:

shell for redeye program

Author: J.S. Newacheck

Uses all applicable rules in data derivations.

Probability System: 0 (false) or 1 (true)

DISPLAY THRESHOLD: 1

QUALIFIERS:

1 this rule is

true

false

Name: always true

Used in rule(s): 0001

2 the custom screen will

be shown

not be shown

Name: custom screen

Default value = 1

Used in rule(s): (0001) 0002

3 The program will

halt rule execution and exit to dos

not halt execution but, instead confuse the user and the programmer

Name: 1

Used in rule(s): (0002)

CHOICES:

VARIABLES:

1 X

EXIT VARIABLE

Numeric variable

Initialized to 1.000000

Used in rule(s): (0002)*

Appendix E-3
RULES:

RULE NUMBER: 1 (bob)

IF:

this rule is true

THEN:

the custom screen will be shown

RULE NUMBER: 2

IF:

the custom screen will be shown

THEN:

The program will halt rule execution and exit to dos

and [X] IS GIVEN THE VALUE

Appendix E-4
Appendix F

VGA Files (Figs 1-12)

EGA Files (Figs 13-24)
Figure - 1. EMBLEMV.PCX

Figure -2. TITLE V.PCX

Appendix F-2

COMPUTER AIDED OCULAR ASSESSMENT

1. Make a Diagnosis

2. View Treatment Protocols

3. Use the Tutorial

4. Exit to DOS
Corneal Sensitivity Measurement

1. Pull and twist the tip of a cotton tipped applicator to form a fine strand of cotton

fiber.

2. Have your patient look upward. Try to keep

the applicator out of your patient's view as you gently touch the fiber tip to the inferior cornea of the unaffected eye. Note your patient's response. Repeat the procedure for

the affected eye.

3. Ask your patient to compare the sensation

between his two eyes. Herpes simplex usually causes reduced sensitivity in the affected eye.

Figure- 3. CORNSNSV.PCX

Dendritic Keratitis

The figure to the right shows a classic dendritic lesion characteristic

of herpes simplex. Note the branching

pattern of the lesion. A herpetic

lesion generally appears clean (i.e. no purulent or mucoid discharge) and is

fairly superficial. affecting only the

corneal epithelium.

In this figure, the same lesion

has been stained with fluorescein dye.

The dye enhances the visibility of the

lesion in the latter stages of herpes keratitis. Because the berpes virus

affects the sensory neurons of the

cornea, cernial sensitivity is often

reduced in an eye with an active herpes infection. A corneal sensitivity test can be performed to demonstrate reduced

corneal sensitivity.

Figure - 4. DENDRITV.PCX

Appendix F -3
Superior fornix conjuntiva

Superior buhlbar

conjunctiva

Superior palpebral conjunctiva

Cornea

Inferior palpebral conjunctiva

Inferior bulJiar

conjunctiva

Inferior fornix conjunctiva

Figure -5. ANATOMYV.PCX

S U r

2

exposed palpebral

conjunct iva

1. Have your patient look downward: grasp the upper lashes end pull the upper lid away

1. Have your patient look downward; grasp the upper lashes and pull the upper lid away from the globe

2. Use a cotton tipped applicator to apply pressure along the superior part of the lid

3. Flip the upper lid over the applicator, exposing the under surface of the lid

3

Figure - 6. EVERSIOV.PCX

Appendix F-4

1
Foreign Body Tracking Stain

A zig-zag staining pattern, such

as the one shewn to the right, usually y. -. indicates a foreign body under the -- upper eyelid. As the lid moves up and

down with each blink, and the eye moves left and right. the foreign body is

dragged across the cornea, causing this

characteristic staining pattern. After the foreign body is located

and remoned. ticatment fod the coneal abrasion is indicated.

Figure- 7. FBTRACKV.PCX

Corneal Infiltrate

Corneal Infiltrates represent the migration of white blood cells into the cornea.

They can be scattered throughout the

comes in which case they ae almost

impossible to see without he aid of a

microscope. Infiltrates can also coalesce

in one part of the comere as shown in the

picture to the right. This type of corneal

infiltration is often visible to the naked

eye. It is also the most worrysomeo as it Corned Ir, nin

may be indicative of overlying corneal

ulceration. If coalesced corneal infiltrate

is accompanied by fluorescein staining at the same location, corneal ulcer is a likely diagnosis. Even without overlying staining, a coalesced infiltrate must

be treated aggressively with antibiotics.

Figure - 8. INFILTV.PCX

Appendix F -5

I Press <Entei-> to continue: I
Schiotz Tonometr

Keep the plunger

mechanism oriented

vertically. Lower

the tonometer onto

the eye until a steady reading is

achieved.

- Do not

any of

moving

of the

meter

Holth lids open, but

don't apply any direct

pressure to the globe

Figure - 9. SCHIOTZV.PCX

ConjuncMtiva Antomy

"r- Palpebral conjunctiva

6- Fornix conjunctiva

7Bulbar conjunct iva

Caiuncle Linbss

Many people mistakenly report "sclorl" redness when

what they are PeallV seeing is contunctival inElammation.

The eclera rarely becomes inflamed, and when it does. it

looks quite different from the common conjunctival pink eye. The conjunctiva is a normally clear thin tissue that overlie.

the scl•ra (bulbar conjunctiva). reflects back (fornix) to

line the Insides of the eyelids Coaluebral con.unctiva).

Figure - 10. CONJV.PCX

Appendix F-6

touch

the

parts

tonoI
Triaeminal Nerve

Almost all of the sensory nerve fibers

from the face are gathered to form the sensory

root of the trigeminal nerve. The ophthalmic

branch of the trigeminal nerve innervates /

the eye and surrounding tissues. App- ('.

roximately 900 to 1200 myelinated and

unmyelinated axons convey sensory

signals from the cornea, making it one of

the most richly innervated structures in the

human body.

Mandibular division

Maodllajy division /

Figure- 11. TRIGEMV2.PCX

Refractive Error

Emmetropia

Myopia

Figure - 12. VISIONV.PCX

Appendix F -7

H-lyperopia

I Press <FnIer> In continue- I
Figure - 13. EMCNBLUE.PCX

Computer

I2.

3-

4-

Aided Ocular Assessment

Make a Diagnosis

View Treatment Protocols

Us. the Tutorial

Exit to DOS

Figure - 14. TITLE.PCX

Appendix F -8
Corneal Sensitivity Measurement

1. Pull and twist the tip of a cotton tipped

applicator to form a fine strand of cotton

fiber.

2. Haue your patient look upward. Try to keep

the applicator out of your patient's uiew as you gently touch the fiber tip to the inferior cornea of the unaffected eye. Note your

patient's response. Repeat the procedure for

the affected eye.

3. Ask your patient to compare the sensation

between his two eyes. Herpes simplex usually causes reduced sensitiuity in the affected eye.

Prs <Etr to cninu

Figure - 15. CORNSNS.PCX

Dendndic Keratitis

The classic sign of a recurrent herpes simplex infection

of the eye is dendridic keratitis. This type of keratitis .,.

is characterized by a branching pattern with club shaped

end bulbs. Fluorescein stains the affected parts of the

cornea, highlighting the dendritic pattern. Sometimes

atypical staining patterns occur with ocular herpes

infections. These include geographic or map-like patterns ,,, -

and superficial punctate (pinpointq keratitis.

Pr.s <Etr to cninu

Figure - 16. DENDRIT.PCX

Appendix F-9
Superior fornix conjunctiva

Tarsal

plate

Cornea

Anterior

chamber

I Inferior fornix conjunctiva Infrerior palpebral conjunctiva

Figure - 17. ANATOMY.PCX

1. Have your patient look downward; grasp the upper lashes and pull the upper lid away

from the globe

2. Use a cotton tipped applicator to apply pressure along the superior part of the lid

3. Flip the upper lid over the applicator, exposing the under surface of the lid

Pres <Etr to cninue

Figure - 18. EVERSION.PCX

Appendix F -10

Press <Enter> to continue

I

g

I

I I
Foreign Body Tracking Stain

A zig-zag staining pattern, such as the one shown to the right, usually

indicates a foreign body under the

upper eyelid. As the lid moves up and

down with each blink, and the eye moves left and right, the foreign body is

dragged across the cornea, causing this

characteristic staining pattern. After the foreign body is located

and removed, treatment for the corneal

abrasion is indicated.

Pres <Etr to cninu

Figure - 19. FBTRACK.PCX

Corneal Infiltrates

Corneal Infiltrate

Corneal infiltrates can occur anywhere on the cornea. Because they are often indicators of corneal ulceration, they

must be treated with great care, especially in the isolated

submarine enuironment.

Prs <Etr to cninue

Figure - 20. INFILT.PCX

Appendix F- 11

I I

I I
Schiotz Tonometr

Keep the plunger mechanism oriented

vertically. Lower

the tonometer onto

the eye until a

steady reading is

achieued.

,Do not touch

any of the

moving parts

of the tonemeter

Hold the lids open, but

don't apply any direct

pressure to the globe

Pr.s <Etr to cotiu

Figure - 21. SCHIOTZ.PCX

Coniunctival Anatomy

-- Palpebral conjunctiva

Fornix conjunctiva

Bulbar conjunctiva

Caruncle Limbus

Many people mistakenly report "scleral" redness when

what they are really seeing is conjunctival inflammation.

The sclera rarely becomes inflamed, and when it dees. it

looks quite different from the common conjunctival pink eye.

The conjunctiva is a normally clear thin tissue that overlie:

the scleira (bulbar conjunctiva), reflects back (fornix) to

line the insides of the eyelids (valoebral con.junctiva).

Figure - 22. CONJ.PCX

Appendix F -12

I I

Press <Enter> to continue

I I
Almost all of the sensory nerve fibers from

the face are gathered to form the sensory

root of the trigeminal nerve. The ophthalmic

branch of the trigeminal nerve innervates the

eye and surrounding tissues. Approximately

900 to 1200 myelinated and unmyelinated

axons convey sensory signals from the

cornea, making it one of the most richly

Innervated structures In the human

body. Maxlary division

Mandibular divaion

Prs - to reur to prora

Figure - 23. TRIGEM2.PCX

Refractive Error

Refractive error can be

thought of as the need for

corrective lenses. With

emmetropia, light focuses

properly on the retina and

no lenses are needed.

Light focuses behind the

retina with hyperopia

[far-sightedness). With

myopia (near-sightednessj,

light comes to a focus in

front of the retina.

Emmetropla

Hyperopla

Myopia

Figure - 24. RE.PCX

Appendix F- 13

Press <Enter> to continue

I

I

II

I I
"UNCLASSIFIED -bIhWUI I Y ULRbb1IHKA I IVN Ut- I MIb IAtml

Form Approved

REPORT DOCUMENTATION PAGE OMB No. 074-0186

la. REPORT SECURITY CLASSIFICATION 1b. RESTRICTIVE MARKINGS

UNCLASSIFIED

2a. SECURITY CLASSIFICATION AUTHORITY 3. DISTRIBUTION/AVAILABILITY OF THE REPORT

Approved for public release;

2b. DECLASSIFICATION/DOWNGRADING SCHEDULE distribution unlimited

4. PERFORMING ORGANIZATION REPORT NUMBER(S) 5. MONITORING ORGANIZATION REPORT NUMBER(S)

NSMRL Report 1173 NA

6a. NAME OF PERFORMING ORGANIZATION 6b. OFFICE SYMBOL 7a. NAME OF MONITORING ORGANIZATION

Naval Submarine Medical (If Applicable) Naval Medical Research and Development

Research Laboratory Command

6c. ADDRESS (City, State, Zi Code) 7b0. ADDRESS (City, State, Zip Code)

Box 900, NAVSUBASE NLON Naval Medical Center Bld 1, Tower 12,

Groton, CT 06349-5900 Bethesda, MD 20885-5644

8a. NAME OF FUNDING/SPONSORING 8b. OFFICE SYMBOL 9. PROCUREMENT INSTRUMENT IDENTIFICATION NUMBER

ORGANIZATION (If Applicable)

Same as 7a

8c. ADDRESS (City, State, Zo Code) 10. SOURCE OF FUNDING NUMBERS

Same as 7b PROGRAM PROJECT NO. TASK NO. WORK UNrr ELEMENT NO. A SI

11. TITLE (Include Security Classifcation)

COMPUTER AIDED OCULAR ASSESSMENT: PROGRAMMER'S MANUAL

12. PERSONAL AUTHOR(S)

J. Newacheck

13a. TYPEOFREPORT 13b. TIME COVERED 14. DATE OF REPORT (Yew, Mof*, Day) 15. PAGE COUNT

Interim FROM _ TO_ 91 Sep 21 252

16. SUPPLEMENTARY NOTATION

17. COSATI CODES 18. SUBJECT TERMS (Continue on reverse if necessary and identify by block number)

FIELD GROUP SUB-GROUP Computer aided diagnosis; ocular, Programmer's Manual

19. ABSTRACT (Continue on reverse if necessary and identi fyby block number)

Computer Aided Ocular Assessment (CAOA) is a computer program designed to aid submarine

Independent Duty Corpsmen with the diagnosis and treatment of eye disease. This manual serves as a

programmer's reference for the program. It provides complete documentation of all of the program's

source code. In addition, selected portions of the code are thoroughly explained.

Expertise with the Exsys Professional expert system development package is required to use this manual

effectively.

20. DISTRIBUTION/AVAILABILITY OF ABSTRACT 21. ABSTRACT SECURITY CLASSIFICATION

[X]UNCLASSIFIED/UNLIMrTED []-SAME AS REPORT [J)TIC USERS UNCLASSIFIED

22a. NAME OF RESPONSIBLE INDIVIDUAL 22b. TELEPHONE (include Ama Code) 22c. OFFICE SYMBOL

S. Monty, Publications Office (203) 449-3967

1. _1. 00 al-' lo IDI p 'V AQ0I4'IrATI " tCr n TUI:1 DAt-.

DD Form 1473, JUN 86 P-'revious ecawons are oosotere.

S/N 0102-LF-014-6603 UNCLASSIFIED

glli•unl i •li.tlgtllrlVl-i i i!•/ill vr i, iltll • •
M.UM 17 IT LLMiIMCIA 1101JI'4 L1 I MIS PAGE~

SECURrIY CLASSIFICATION OF THIS PAGE DD Form 1473, JUN 86 (Reverse)