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American Academy of Ophthalmology
655 Beach Street
P.O. Box 7424
San Francisco, CA 94120-7424
Clinical Education Secretaries
Louis B. Cantor, MD, Senior Secretary for Clinical Education
Christopher J. Rapuano, MD, Secretary for Ophthalmic Knowledge
Ophthalmology Liaisons Committee
Samuel P. Solish, MD, Chair
Richard C. Allen, MD, PhD
Rebecca Sands Braverman, MD
Humeyra Karacal, MD
Joseph T. Nezgoda, MD, MBA
Martha P. Schatz, MD
Howard S. Weiss, MD
Diana J. Shamis, COMT, Consultant

Academy Staff
Dale E. Fajardo, Vice President, Education
Beth Wilson, Director, Continuing Professional Development
Daniel Mummert, Director, Online Education
Susan R. Keller, Acquisitions Editor
Kim Torgerson, Publications Editor
D. Jean Ray, Production Manager
Jasmine Chen, Manager, E-Learning
Donna Scism, E-Editor/Proofreader
Eric Gerdes, Interactive Designer
Debra Marchi, Administrative Assistant
The Academy provides this material for educational purposes only. It is not
intended to represent the only or best method or procedure in every case, nor to
replace a physician’s own judgment or give specific advice for case management.
Including all indications, contraindications, side effects, and alternative agents for
each drug or treatment is beyond the scope of this material. All information and
recommendations should be verified, prior to use, with current information
included in the manufacturers’ package inserts or other independent sources, and
considered in light of the patient’s condition and history. Reference to certain
drugs, instruments, and other products in this publication is made for illustrative
purposes only and is not intended to constitute an endorsement of such. Some
materials may include information on applications that are not considered
community standard, that reflect indications not included in approved FDA
labeling, or that are approved for use only in restricted research settings. The
FDA has stated that it is the responsibility of the physician to determine
the FDA status of each drug or device he or she wishes to use, and to
use them with appropriate informed patient consent in compliance with
applicable law. The Academy specifically disclaims any and all liability for injury
or other damages of any kind, from negligence or otherwise, for any and all claims
that may arise out of the use of any recommendations or other information
contained herein.
AAO, AAOE, American Academy of Ophthalmology, Basic and Clinical Science
Course, BCSC, EyeCare America, EyeNet, EyeSmart, EyeWiki, Focal Points, IRIS,
ISRS, OKAP, ONE, Ophthalmic Technology Assessments, Ophthalmology, Preferred
Practice Pattern, ProVision, SmartSight, The Ophthalmic News & Education
Network, and the AAO logo (shown on cover) and tagline (Protecting Sight.
Empowering Lives) are, among other marks, the registered trademarks and
trademarks of the American Academy of Ophthalmology.

Copyright © 2016 American Academy of Ophthalmology®. All rights reserved.

Financial Disclosures
Authors, reviewers, and academy staff members who contributed to the
development of this product state that within the 12 months prior to their
contributions to this book and for the duration of development, they have had no
financial interest in or other relationship with any entity discussed in this course
that produces, markets, resells, or distributes ophthalmic health care goods or
services consumed by or used in patients, or with any competing commercial
product or service.

Library of Congress Cataloging-in-Publication Data

Names: Allen, Richard C. (Richard Cutler), 1965- editor. | Harper, Richard A., 1958-
editor. | American Academy of Ophthalmology, issuing body.
Title: Basic ophthalmology : essentials for medical students / Richard C. Allen,
Richard A. Harper, executive editors.
Other titles: Basic ophthalmology (Bradford)
Description: Tenth edition. | San Francisco, CA : American Academy of
Ophthalmology, [2016] | Includes bibliographical references and index.
Identifiers: LCCN 2016020313 | ISBN 9781615258048 (alk. paper)
Subjects: | MESH: Eye Diseases--diagnosis | Diagnostic Techniques,
Ophthalmological
Classification: LCC RE46 | NLM WW 141 | DDC 617.7--dc23 LC record available at
https://lccn.loc.gov/2016020313
Printed in the United States of America
20 19 18 17 16 1234
CONTENTS

Preface
Acknowledgments
About the Executive Editors

Introduction to Ophthalmology
Resources from the American Academy of Ophthalmology
Meet the Eye Care Team
Eye Myths

1 The Eye Examination

Objectives
Relevance
Basic Information
The Patient’s History
Ocular Anatomy
Anatomic Aging Changes
Optics
When to Examine
Additional Tests
How to Examine
Visual Acuity
Distance Visual Acuity Testing
Near Visual Acuity Testing
Visual Acuity Estimation in an Uncooperative Patient
Confrontation Visual Field Testing
Amsler Grid Testing
External Inspection
Upper Eyelid Eversion
Ocular Motility Testing
Pupillary Reaction Testing
Anterior Chamber Depth Assessment
Intraocular Pressure Measurement
Color Vision Testing
Fluorescein Staining of Cornea
 Ophthalmoscopy
Summary of Steps in the Eye Examination
Management or Referral
Reduced Visual Acuity
Abnormal Fundus Appearance
Shallow Anterior Chamber Depth/Elevated Intraocular Pressure
Points to Remember
Sample Problems
Annotated Resources

2 Acute Vision Loss

Objectives
Relevance
Basic Information
Narrowing the Diagnosis From the History
How to Examine
Visual Acuity Testing
Confrontation Visual Field Testing
Pupillary Reactions
Red Reflex Evaluation and Ophthalmoscopy
Penlight Examination
Tonometry
How to Interpret the Findings
Acute Vision Loss Associated With Pain
Acute Vision Loss Without Pain
Painless, Acute Vision Loss Without Clear Media
Painless, Acute Vision Loss With Clear Media
Functional Disorders
Points to Remember
Sample Problems
Annotated Resources

3 Chronic Vision Loss

Objectives
Relevance
Basic Information
Glaucoma
Overview
When to Examine
How to Examine
How to Interpret the Findings
 Management or Referral
Cataract
Overview
When to Examine
How to Examine
How to Interpret the Findings
Management or Referral
Macular Degeneration
Overview
When to Examine
How to Examine
How to Interpret the Findings
Management or Referral
The Visually Impaired Patient
Points to Remember
Sample Problems
Annotated Resources

4 The Red Eye

Objectives
Relevance
Basic Information
History
How to Examine
Disorders Associated With a Red Eye
The Acute, Painful Red Eye
Acute, Nonpainful Red Eye
Chronic, Irritated Red Eye
Chronic Red Eye Without Irritation
Adnexal Disease
Further Interpretation of the Findings
Symptoms of a Red Eye
Signs of a Red Eye
Associated Systemic Problems
Laboratory Diagnosis
Management or Referral
Blepharitis
Stye and Chalazion
Subconjunctival Hemorrhage
Conjunctivitis
Therapeutic Warnings
Points to Remember
 Sample Problems
Annotated Resources

5 Ocular and Orbital Injuries

Objectives
Relevance
Basic Information
Anatomy and Function
When to Examine
How to Examine
History
Visual Acuity Testing
External Examination
Pupillary Reactions
Ocular Motility Testing
Ophthalmoscopy
Radiologic Studies
Management or Referral
True Emergency
Urgent Situations
Treatment Skills
Ocular Irrigation
Foreign-Body Removal
Prescribing Eye Medication
Patching
Points to Remember
Sample Problems
Annotated Resources

6 Amblyopia and Strabismus

Objectives
Relevance
Basic Information
Amblyopia
Strabismus
How to Examine and Interpret the Findings
Amblyopia Testing
Strabismus Testing
Other Tests
Management or Referral
Amblyopia
 Strabismus
Serious Intraocular Lesions
Points to Remember
Sample Problems
Annotated Resources

7 Neuro-Ophthalmology
Objectives
Relevance
Basic Information
How to Examine
Visual Acuity Testing
Visual Field Testing
Color Perception and Saturation
Pupillary Examination
Ocular Motility Testing
Ophthalmoscopy
How to Interpret the Findings
Pupillary Disorders
Motility Disorders
Optic Nerve Disease
Optic Disc Elevation
Visual Field Defects
Visual Hallucinations
Cognitive Vision Loss: The Visual Variant of Alzheimer’s Disease
Points to Remember
Sample Problems
Annotated Resources

8 Eyelid, Lacrimal, and Orbital Disease

Objectives
Relevance
Eyelid Disorders
Eyelid Infections
Eyelid Malpositions
Eyelid Neoplasms
Lacrimal Disease
Orbital Disease
How to Examine
Orbital Neoplasms
Inflammatory Processes of the Orbit
 Vascular Malformations
Points to Remember
Sample Problems
Annotated Resources

9 Ocular Manifestations of Systemic Disease

Objectives
Relevance
Diabetes Mellitus
Hypertension
Arteriolar Sclerosis
Elevated Blood Pressure
Diagnostic Concerns
Management
Pregnancy
Sickle Cell Anemia
Thyroid Disease
Sarcoidosis and Other Inflammatory and Autoimmune Conditions
Dry Eye Syndrome
Malignancy
Acquired Immunodeficiency Syndrome
Syphilis
Other Systemic Infections
Points to Remember
Sample Problems
Annotated Resources

10 Drugs and the Eye

Objectives
Relevance
Basic Information
Topical Ocular Diagnostic Drugs
Fluorescein Dye
Anesthetics
Mydriatics
Topical Ocular Therapeutic Drugs
Decongestants
Agents for Relief of Allergic Conjunctivitis
Anti-inflammatory Agents
Agents for the Relief of Dry Eye Symptoms
Antibiotics
 Antiviral Agents
Systemic Side Effects of Glaucoma Medications
β-Adrenergic Antagonists
Cholinergic-Stimulating Drugs
α2-Adrenoceptor Agonists
Adrenergic-Stimulating Drugs
Prostaglandin Analogues
Carbonic Anhydrase Inhibitors
Ocular Side Effects of Systemic Drugs
Amiodarone
Bisphosphonates
Chloroquines
Chlorpromazine
Corticosteroids
Digitalis
Diphenylhydantoin
Ethambutol
HMG-COA Reductase Inhibitors (Statins)
Rifabutin
Sildenafil, Tadalafil, Vardenafil, and Avanafil
Tamoxifen
Tamsulosin
Thioridazine
Topiramate
Points to Remember
Sample Problems
Annotated Resources
PREFACE
Basic Ophthalmology: Essentials for Medical Students is an ideal
complement to the medical student curriculum and a key text for
primary care providers and residents who want to broaden their
knowledge of eye disease diagnosis and treatment. The book
describes how to obtain an appropriate ocular history and perform a
complete eye evaluation. From the history and clinical findings, the
clinician should be able to diagnose and manage or refer common
ocular disorders such as vision loss, red eye, ocular and orbital
injuries, and amblyopia and strabismus. This edition includes content
updates as well as a new chapter on eyelid, orbital, and lacrimal
disease. Other features include 140+ figures, access to 19 video
clips, key points to remember, sample problems to test knowledge,
plus updated annotated resources. Where appropriate, tables are
presented to summarize textual information and facilitate study.
Population growth in persons 65 years and older in the United
States is placing increasing demands on primary care providers to
manage age-related disease. Because many ocular disorders are
more prevalent in this age group, primary care providers will need to
have a solid understanding of the most commonly encountered
disorders so that patients’ conditions will be effectively diagnosed,
treated, and/or referred. To complicate this situation, there has been
a decline in the number of medical schools requiring a formal
ophthalmology rotation, thus reducing the opportunity for medical
students to obtain this essential information. Fortunately, many
ophthalmology departments around the country are taking an active
role in reemphasizing the importance of ophthalmology in the
medical student curriculum. Basic Ophthalmology provides an
excellent resource for this effort, by establishing curricular content
and later acting as a ready reference for practitioners encountering
patients with ocular disorders.
 This book can be used in a variety of settings. The concise
presentation of information makes it ideal for brief ophthalmology
rotations. If greater time is available, the resources can be consulted
for more detail. This book is intended to be a flexible instrument that
summarizes the important concepts, techniques, and facts of
ophthalmology for nonophthalmic physicians and residents,
especially those in primary care. The Ophthalmology Liaisons
Committee anticipates that medical students will use this book in
conjunction with comprehensive texts and other related resources
listed at the end of each chapter.
New to this edition are videos related to topics covered in the
book (see Chapters 1, 3, 6, 7, 9, and 10). The videos are available to
readers of the print and electronic versions at
www.aao.org/basicvideo. For the print version, mobile-device users
can scan the QR codes shown in text (a QR-code reader must
already be installed on the device) to access the video content. In
addition, you are invited to test your knowledge of anatomy through
interactive versions of some figures in this book. Visit
www.aao.org/basicinteractive.

Acknowledgments

The executive editors of this edition thank the members of the

Ophthalmology Liaisons Committee who reviewed the previous
edition for currency and offered feedback for this edition: Samuel P.
Solish, MD, chair; Richard C. Allen, MD, PhD; Rebecca Sands
Braverman, MD; Humeyra Karacal, MD; Joseph T. Nezgoda, MD,
MBA; Martha P. Schatz, MD; Howard S. Weiss, MD; and Diana J.
Shamis, COMT, consultant.

About the Executive Editors

Richard C. Allen, MD, PhD, is professor of ophthalmology in the

Department of Head and Neck Surgery at MD Anderson Cancer
Center in Houston, Texas. He is editor of the oculoplastics and orbit
section for Current Opinion in Ophthalmology and is a member of
committees in the American Society of Ophthalmic Plastic &
Reconstructive Surgery, the American Academy of Ophthalmology,
and the International Council of Ophthalmology.
Richard A. Harper, MD, is professor of ophthalmology at the
Harvey & Bernice Jones Eye Institute of the University of Arkansas
for Medical Sciences in Little Rock, Arkansas, where he served, until
recently, as director of the residency program and the low vision
clinic. He is a recipient of the Straatsma Award for excellence in
resident education, established through the American Academy of
Ophthalmology and the Association of University Professors of
Ophthalmology.
Introduction to Ophthalmology

Resources from the American Academy of

Ophthalmology
The mission of the American Academy of Ophthalmology is to
protect sight and empower lives by serving as an advocate for
patients and the public, leading ophthalmic education, and
advancing the profession of ophthalmology. The following are
trusted resources for additional information:

Information for medical students interested in pursuing a

career in ophthalmology: www.aao.org/medical-students
Quality clinical ophthalmic content from EyeWiki™
collaborative online encyclopedia: www.aao.org/eyewiki
Clinical information and education for pediatric eye care:
www.aao.org/pediatric-ophthalmology-education-center
EyeSmart® eye health information for patients and the
public: www.aao.org/eye-health
EyeCare America® eye care for patients in need:
www.aao.org/eyecare-america

Meet the Eye Care Team

M
any participants have important roles in the delivery of eye care.
The support staff of the clinic, hospital, and operating
room are critical. There are also specialized ophthalmic
nurses and technicians. The levels of training and expertise are
quite different for each type of care provider.

Ophthalmologist

An ophthalmologist is a medical or osteopathic doctor who

specializes in eye and vision care. Ophthalmologists differ from
optometrists and opticians in their levels of training and in what they
can diagnose and treat. As a medical doctor who has completed
college and at least eight years of additional medical training, an
ophthalmologist is licensed to practice medicine and surgery. An
ophthalmologist diagnoses and treats all eye diseases, performs eye
surgery, and prescribes and fits eyeglasses and contact lenses to
correct vision problems. Many ophthalmologists are also involved in
scientific research on the causes of and cures for eye diseases and
vision disorders.

Subspecialists

Whereas ophthalmologists are trained to care for all eye problems

and conditions, some ophthalmologists specialize in a specific area of
medical or surgical eye care. A subspecialist usually completes 1 or 2
years of additional, more in-depth training called a fellowship in one
of the main subspecialty areas such as glaucoma, retina, cornea,
pediatrics, neurology, and plastic surgery, as well as others. This
added training and knowledge prepares an ophthalmologist to take
care of more complex or specific conditions in certain areas of the
eye or in certain groups of patients.

Optometrist

Optometrists are healthcare professionals who provide primary vision

care ranging from sight testing and correction to the diagnosis,
treatment, and management of vision changes. An optometrist is not
a medical doctor. An optometrist receives a doctor of optometry
(OD) degree after completing four years of optometry school,
preceded by three years or more years of college. They are licensed
to practice optometry, which primarily involves performing eye
exams and vision tests, prescribing and dispensing corrective lenses,
detecting certain eye abnormalities, and prescribing medications for
certain eye diseases.

Optician

Opticians are technicians trained to design, verify and fit eyeglass

lenses and frames, contact lenses, and other devices to correct
eyesight. They use prescriptions supplied by ophthalmologists, who
are medical doctors and surgeons, or by optometrists, but they do
not test vision or write prescriptions for visual correction. Opticians
are not permitted to diagnose or treat eye diseases.

Ophthalmic Medical Assistant

These technicians work in the ophthalmologist’s office and are

trained to perform a variety of tests and help the physician with
examining and treating patients.

Ophthalmic Technicians/Technologists

These are highly trained or experienced medical assistants who

assist the physician with more complicated or technical medical tests
and minor office surgery.

Ophthalmic Registered Nurse

These clinicians have undergone special nursing training and may

have additional training in ophthalmic nursing. They may assist the
physician in more technical tasks, such as injecting medications or
assisting with hospital or office surgery. Some ophthalmic registered
nurses also serve as clinic or hospital administrators.

Ophthalmic Photographer

These individuals use specialized cameras and photographic methods

to document eye conditions in photographs.

Eye Myths
The following statements are oft-repeated myths. They are
presented here, with counterpoint, in the event patients may report
to you what they have heard.

Reading for prolonged periods in dim light can be

harmful to the eyes.
Reading in dim light does not harm the eyes any more
than taking a photograph in dim light would harm a
camera.
Children should be taught not to hold their books too
close when reading, because doing so can harm their
eyes.
Holding books close to the eyes to read is common in
children, and no harm can come of it. Their eyes can
accommodate (focus on near objects) easily and can
keep near objects in sharp focus. In rare cases, holding a
book close could be a sign of severe nearsightedness,
which should be investigated; however, the habit of close
reading itself will not cause nearsightedness in children.
Wearing glasses that are of the incorrect prescription
can damage the eyes.
Because glasses are placed in front of the eyes, they
affect sight, not the eye. Looking through them cannot
 harm the eyes. However, an incorrect prescription may
result in blurred vision, which can be uncomfortable.
If children sit too close to the television set, they may
damage their eyes.
Children with normal sight commonly want to sit close to
the television set, just as they want to get close to
reading material. This will not harm their eyes.
Individuals will typically hold reading material or watch
television at a distance that is comfortable for them.
Older people who may be having trouble seeing
should not use their eyes too much because they can
wear them out sooner.
The eyes are made for seeing. No evidence exists that
using them for their purpose will wear them out.
People with weak eyes should rest their eyes often to
strengthen them.
Eyes that are “weak” for whatever reason did not become
so from overuse, so they cannot be improved by rest.
In time, children usually outgrow crossed eyes.
Crossed eyes in children should always be considered
serious; in fact, the condition requires referral to an
ophthalmologist. Some children have apparent but not
truly crossed eyes. In such cases, the apparent crossing
is due to a broad bridge of the nose in young children. As
the nose matures, this apparent crossing lessens and
disappears. However, truly crossed eyes should never be
ignored, as the condition will not improve with time.
Contact lenses can correct nearsightedness, so that
eventually neither contact lenses nor eyeglasses will
be needed.
Incorrectly fitted contact lenses can change the shape of
the cornea but do not thereby correct myopia.
Intentionally fitting contact lenses incorrectly to change
corneal shape can cause permanent harm to the eyes.
Children who have a problem learning to read are
likely to have an eye coordination problem and can be
helped with special exercises.
The idea that reading problems are due to poor eye
coordination is a misconception, as the results of many
controlled studies have indicated.
A cataract can sometimes grow back after cataract
surgery.
Because a cataract is an opacity in the lens of the eye,
the cataract cannot grow back when the entire lens is
removed (intracapsular extraction). However, the
posterior capsule of the lens may opacify when the lens
capsule is left in place after removing the lens material
(extracapsular extraction). This latter technique is
nevertheless currently preferred because it best permits
the placement of an intraocular lens implant; if posterior
capsule opacity develops, it can be easily addressed with
an outpatient laser procedure.
A cataract has to be “ripe” before surgery can be
done.
The need for cataract surgery is indicated principally by
the degree of functional impairment caused by the
cataract, not by any criteria related to its duration.
Nearsighted people become farsighted as they age,
and farsighted people become nearsighted.
All individuals become presbyopic as they age. Presbyopia
is the gradual loss of the ability to accommodate (focus
on near objects), and it occurs irrespective of the
person’s underlying refractive error.
In older people, a sign of healthy eyes is the ability to
read the newspaper without glasses.
The ability of older persons to read without glasses may
show only that they have myopia in at least one eye with
reasonably good visual acuity. The nearsightedness could
 be caused by a cataract. Despite this ability, the person
could also have a serious ocular disorder that was not yet
symptomatic, such as glaucoma.
People who wear glasses should have their vision
checked every year to determine whether a change in
prescription is needed.
Glasses do not affect the health of the eyes. As long as
an individual is satisfied with the vision provided by the
present glasses, routine tests to measure their glasses
prescription are generally unnecessary.
Watching a bright television picture in a dimly lighted
room can be harmful to the eyes if done for long
periods.
The eye cannot be harmed by the way in which light
enters it. The eye merely deals with light, regardless of
contrast. Watching television with or without illumination
is a matter of comfort rather than harm. An individual
who finds the marked contrast of a bright television
picture in a dimly lighted room uncomfortable should turn
on a light, but neither situation will harm the eyes.
Ideally, all people should use an eyewash regularly to
cleanse their eyes.
Eyewash should be used as infrequently as possible. As
long as it is functioning properly, the eyes’ natural
lubrication system is adequate for cleansing them.
A blue eye should not be selected for transplantation
into a brown-eyed person.
Only the cornea can be transplanted, and the cornea is
colorless in all eyes. (The iris gives eyes their color.)
In rare instances, a contact lens can be lost behind
the eye and even work its way into the brain.
The conjunctiva prevents a contact lens from passing
behind the eye.
A cataract is actually a film over the eye that can be
peeled off with surgery.
A cataract is a loss of the transparency of the normal lens
of the eye, not a “growth” or “film” that covers the eye. If
the lens becomes opaque enough to significantly impair a
person’s functional vision, the lens can be surgically
removed and replaced with an intraocular lens implant.
Nothing is “peeled” away.
Headaches are usually due to eye strain.
Headaches are not usually caused by ocular factors. You
will find more detailed and specific rationales for these
answers in the various chapters of this text and in the
resources suggested at the end of each chapter.
CHAPTER 1

The Eye Examination

This chapter includes related videos.
Links to individual videos are provided
within the text; a page containing all
videos in this book is available at
www.aao.org/basicvideo.
 OBJECTIVES
As a primary care provider, you should be able to recognize the
significant external and internal ocular structures of the normal
eye and to perform a basic eye examination. To achieve these
objectives, you should learn to

elicit history and symptoms of ocular disease

recognize the essentials of ocular anatomy
identify anatomic changes of the eye due to aging
measure and record visual acuity
evaluate visual fields by confrontation
evaluate the eyelids
evaluate ocular motility
assess pupillary reactions
dilate the pupils when needed as an adjunct to
ophthalmoscopy
use the direct ophthalmoscope for a systematic fundus
examination and assessment of the red reflex
know when a referral to an ophthalmologist is necessary

Relevance

T
he proper performance of a basic eye examination is a crucial
skill for the primary care provider. Systematic examination of the
eye enables you to properly evaluate ocular complaints and provide
either definitive treatment or appropriate referral to an
ophthalmologist. Many eye diseases are “silent,” or asymptomatic,
while serious ocular damage is occurring. Obtaining a thorough
history and performing a basic eye examination can reveal such
conditions and ensure that patients receive the timely care they
need. A basic eye examination may provide early warning signs of
any of the following conditions: blinding eye disease, systemic
disease, and tumor or other disorders of the brain. Important
examples of irreversible blinding eye diseases that are potentially
treatable if discovered early include glaucoma, diabetic retinopathy,
macular degeneration, retinal detachment, and, in young children,
amblyopia. Potentially vision-threatening or life-threatening systemic
disorders that may involve the eye include diabetes, hypertension,
temporal arteritis, and an embolism from the carotid artery or the
heart. Tumors or other disorders of the brain, orbit, or eye may
threaten both vision and life. Important examples include
meningioma, melanoma, retinoblastoma, aneurysms, and multiple
sclerosis.

Basic Information
An understanding of the patient’s history as well as knowledge of
ocular anatomy, anatomic aging changes, and optics all come into
play when evaluating ocular complaints.

The Patient’s History

When a patient presents to a primary care provider with ocular

complaints, the first priority is to obtain a thorough ocular history.
This is critical in making the diagnosis and implementing a treatment
plan.

Assessing risk factors for ocular disease

Obtaining a patient’s systemic medical history and family ocular

history is important for assessing a patient’s risk factors for ocular
disease. Just as with other body systems, reliable historical
information from the previous medical history, social history, and
family history allows the physician to more appropriately direct the
physical examination. Areas to discuss include
 medical history (diabetes mellitus, hypertension,
hyperlipidemia, thyroid disease, autoimmune disease,
malignancy)
history of poor vision (excluding refractive error)
history of eye trauma, eye surgery, or contact lens wear
family history (blindness, glaucoma, ocular tumor, retinal
detachment, strabismus, macular degeneration)

Evaluating visual complaints

Knowing the onset, duration, and associated symptoms of the chief

complaint is invaluable in guiding the examiner to the correct
diagnosis. Questions to ask include

Did the patient have prior good and equal vision in both
eyes?
Is the visual complaint monocular or binocular?
Is central or peripheral vision affected?
Is the change in vision acute or gradual?
Is there any variation during the day?
Is there any pain?
Is vision distorted (metamorphopsia)?
Is there double vision? In 1 eye or both (monocular or
binocular)?

Later chapters give greater detail on historical information

necessary to help diagnose specific ocular disease.

Ocular Anatomy

Figs 1-1 through 1-4 show key external and internal ocular
structures. Table 1-1 describes the principal structures of ocular
anatomy.
FIGURE 1-1 Cross-section of the eye. (Illustration by Christine Gralapp, MA, CMI.)

See Interactive Figure

 Another Random Document on
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 THE VAN METRE GENEALOGY region in Philadelphia
County, Pa., whence he had came via Germantown, — from
Kingston. He is presumed to have been a relative of John Van Metre
through his wife who was Anna Maria DuBois. At the time the grant
was made to the Van Metres, Hite had a large plantation and some
mill property on Perkiomen Creek in what is now Montgomery Co.,
Pa., — a property now owned by Hon. Samuel W. Pennypacker, ex-
Governor of Penna. After Hite had acquired the Van Metre grants it
appears that he entered into a partnership with Robert McKoy, also
of Penna. The transfer by the Van Metres to Hite was made on 5th
Aug., 1731, and on the following 25th of October Messrs. Hite and
McKoy obtained orders from Council for 100,000 acres of land on the
west side of the Blue Ridge under the same conditions, as to its
colonization — were exacted of them as those by which the Van
Metres were bound. It was in that year, 173 1, that Jost Hite and
Robert McKoy made permanent settlement upon their possessions in
Western Virginia (see W. Va. Hist. Mag., Vol. I., pp. 53, 54; also W_.
S. Laidley's letters). Hite having disposed of his lands and mill in
Pennsylvania in 1730 — proceeded with his family of adult children,
some friends and relatives — 16 families in all, — to York, Pa., and
thence by the way of the Indian trail along the Conococheague
through the Cumberland Valley to the Potomac and by passing
through the gap in the Blue Ridge at Harper's Ferry, entered the
Valley of Virginia and made his first settlement, it is claimed, — at
New Muhlenburg (see Times-Despatch, Richmond, Va., 18 Nov.,
1904). Orange Co., Va., was taken from Spottsylvania Co., in 1734
and it was within the limits of the new county of Orange that the
40,000 acres granted to the Van Metres was located, and one of the
first patents issued was for 1,020 acres of land being a part of the
original Van Metre grant made by Virginia to Jost Hite under date of
5 Aug., 1734 (Grant Book, 15, p. 276, Richmond). On the third day
of October, 1734, thirty four grants, for lands in varying quantities,
were made to as many colonists in Orange Co., the aggregate
number of acres being 19,033. Among the various grantees are the
names of John Van IMetre, 885 acres; Thomas Shepherd, 220 acres
; Richard Morgan, 500 acres ; Richard Paulson, 834 acres, and
Benjamin Burden, 1,142 acres. Some of these pioneers were from
the Provinces of East and West Jersey, and were in all probability,
more or less intimately associated with the Van Metres and Hite in
earlier days and localities. Between 1734 and 1744 — the year
following the establishment of Frederick Co., out of Orange Co. — 82
other grants were made to as many dififerent persons ; these grants
probably absorbed the whole of the Van Metre-Hite-McKoy original
interests and the passing of title by these grantors to the many
grantees occasioned long years of contention and litigation between
Hite and McKoy 28
 THE KITE GRANTS AND ASSIGNMENTS of the one part and
Thomas, Lord Fairfax, of the other part, upon the latter's claim that
he had prior ownership of the Northern Neck; the dispute lasted
until 1786 and was finally settled by decree of Court in Hite &
McKoy's favor, and after the two principals had laid long in their
graves. - THE COLONY IN SPOTTSYLVANIA CO., VA. XXVI April,
1734Present : The Governor Cole Digges Will Randolph John
Robinson John Taylor John Grymes Philip Lightfoot, Esq". Thomas
Lee Present also, Com'"''. Blair, William Byrd, John Curtis, Esq'"^ On
readreading a petition from the inhabitants on the North West side
the Blue Ridge of Mountains, praying that: some persons may be
appointed as Magistrates to determine Differences and punish
Offenders in regard; the Petitioners live far remote from any of the
established Counties within the Colony. It is the Opinion of the
Council that Joost Hyte, Morgan Morgan, John Smith, Benjamin
Bourden and George Hobson be appointed Justices within the limits
aforesaid and that they be added to the Com"", of the Peace for the
County of Spottsylvania, until there be sufficient number of
inhabitants on the North West side of s". Mountains to make a
County of itself. But that the persons above named be not obliged to
give their attendance as Justices of the Court of Spottsylvania.
[Journal of Councils, 1721-1734, p. 485; State Library, Richmond,
Va.] Jost Hite and McKay were in 1735, granted extension to settle
"till Christmas, 1735," to comply with the terms of their grants and
in the meantime they may proceed to survey [vide. p. 4941Petition
of St. Marks in Orange County, praying the descretion of the Council
with regard to the poor of the new intended Parish of St. Thomas
already separated from St. Marks, but not yet erected into a parish
of themselves— is postponed until after the Oyer and Terminer Court
;— as also, the petition of the inhabitants of the newly intended
Parish of St. Thomas, praying to be erected into a distinct County
from Orange by name of the County of Frederick, as by law directed,
they answering the — to those now of sufficient number of
inhabitants for that purpose, who are greatly distressed by reason of
their distance from Orange Court — is postponed at the same time.
Council held at the Capital 29 April, 1741 [Vide Vol. 1722-73, p. 35].
1743. Justices named for County of Frederick when erected in
October next — if no opposition takes place: Morgan Morgan.
Richard Borden and others [Vide Vol. 1722-1773, p. 80, State
Library, Richmond, Va.] THE HITE GRANTS AND ASSIGNMENTS On
the 30" June, 1730, an Order of Council was made granting leave to
John Van Metre of New York to take up 10,000 acres of land lying in
the fork of Sherando River, including the places called Cedar Lick and
Stoney Lick, and running up between the branches of the river for
quantity, for the settlement of himself and family of eleven children ;
and 29
 THE VAN METRE GENEALOGY (as soon as he should bring
thirty families to settle the same) 20,000 acres more of lands not
before located by Robert Carter and Mann Page, or any other
persons, lying in the fork of the Sherundo and Cohongoruta, and
extending thence to the Opequon. Two years were allowed to locate
this entry and all others were forbidden to locate the lands in the
meantime. John Van Metre and Isaac Van Metre also obtained leave
by another order of Council, to take up 40,000 acres including the
other 30,000 acres. In 1731 the Van Metres assigned their rights
under these orders of Council, to Joist Hite and Robert McKay of
Pennsylvania; and on i^* October, in same year, on petition of Hite
and McKay, setting forth that they and their families, and an hundred
other families were desirous of removing to Virginia, and praying a
grant of 100,000 acres of land to seat themselves upon, another
Order of Council was made granting them leave to locate that
quantity of land, between the lands of John Van Metre, Jacob
Stoever and John Fishbach and others, and the residue upon and
including the branches of the Sherundo above Stoevers, Fishbach
and his partners; and that upon 100 families migrating and settling
on the lands granted, patents should issue to them for such
proportions as they should agree among themselves. Hite and
company were thus entitled to locate 140,000 acres of land. In June,
1734, an order of Council was made declaring that Hite & Co. had
complied with the terms of the grant, in respect to the first 40,000
acres, and directing that patents should be issued accordingly to the
respective surveys thereof. The surveys were deposited in the Land
Office, but the patents were not issued. Hite and Co., proceeded in
the location of 54 families on them. But the whole 140,000 acres
being within the bounds of the Northern Neck, as claimed by the
Proprietor, he, in 1736, entered a caveat against the issuing of
patents for them ; and as we have seen, the order of the King in
Council, of 1733, had restrained the Colonial government from
perfecting the grants. After the determination of the dispute
between the Crown and the Proprietary, covering the bounds of the
Northern Neck, Hite and his company claimed their patents insisting
that the order of Council under which they claimed, were grants
within the intendment of the Act of 1748, and were therefore
confirmed by that Act, when Lord Fairfax insisted that only the titles
of lands granted by patent were confirmed by the Act. In 1749 Hite
brought suit in Chancery. In 1771, Oct., the Plaintiff obtained a
decree. Lord Fairfax appealed to King and Council. After the
Revolution, Hite appealed to Court of Appeals. The General Court
reversed . . . and case removed to High Court of Chancery. The
papers and decrees in the case afford most complete information as
to the origin and circumstances, etc. [See: Revised Code of Virginia,
Vol. II., 1818-19, pp. 346-7.] JOHN VAN METRE'S DEED OF GIFT
1744, Sept. 17. Deed of gift from John Van Metre of Frederick Co.
Va. for love and affection to Isaac my eldest son, Henry second son,
Abraham third son, Jacob fourth and youngest son; Maudlena, wife
to Roliert Pewsey my youngest daughter, Solomon Hedges Esq"".,
Thomas Shepherd, James Davis, and Robert Jones, _sQnsin la^ —
gives, grants, etc., — , ■ms, ■ .... all stalyons, geldings, mares and
colts', running in the woods, branded on the left shoulder with letter
" M," to be divided equally, the part to my said daughter shall be
appropriated to her use, and under the care of my executors named
in my will. 4 young mares and their increase to each of my
grandsons Johannes Van Metre, son of Johannes deceased; and the
30
 WILL OF JOHN VAN METRE same to John Lessige, son of
my daughter Rachael deceased when they shall arrive at age of 21
years. If the within mentioned Robert Tonea do not quit-claim to a
pretended right to 100 acres of land and other pretended demands
on me, the said John Van Metre, for which he hath no right, then the
proportion of said creatures shall be given to my daughter, Mary wife
to said Tones and to her children at the discression ot my executors.
"* " John Van Meter. Witnesses: Jonas Hedges, Joseph Carroll
[Fredrick Co. Va., Records]. WILL OF JOHN VAN METRE In the name
of God Amen, the Thirteenth day of August one thousand seven
hundred and forty five, I. John Van Metre in Frederick County in the
Colony of Virginia being sick in body but of sound mind and Memory
praise be given to God for the same and calling to mind the
uncertainty of this Transitory Life, am willing tlirough Divine
Assistance to settle and Dispose of those Temporal blessings which it
hath Pleased God beyond my Deserts to bestow upon me and
therefore making this my Last W'ill and Testament Disannulling all
other wills and Testaments heretofore made by me, &c. Imprimis, I
commend my soul into the hands of God that gave it, hoping thro
the merits of the Lord Jesus Christ it will be accepted and my body
to be Interred with Deacency at the Discretion of my executors
hereafter named. I also will that all my Just Debts and Demands
whatsoever in Right of Conscience is Due to any to be Discharged
and paid (as also funeral expenses) By my executors and as to my
Real and Personal Estate, I Will, Dispose Devise Give and Bequeath
it in the manner following, that is to say. First my will is that my well
beloved wife Margerat Van Metre Have the third part of my
moveable estate, also one room which she likes best, to Dwell in, in
my dwelling House, and one third part of the Orchard next the Run
with the keeping of one Riding Horse and two Milch cows, Linnin and
Welling Yarn to be wove her Bed and Bedding the said Room and
Liberties to be by her possessed during Her Dureing Life, without
controle hinderance or molestation of any person whatever. Second,
Item, I give Will Devise and bequeath unto my son Abraham
Van..,Mfiter and his Heirs Lawfully Begotten, a Certain Parcel Tract of
Land Bought by me of Francis Prichard on Opekan Run against the
Land formally Bequeathed to him, said Tract Begins at an Elm Tree
being the East corner of the said Tract between a Line Tree Hickory
Saplin and aforesaid Elm Saplin By Opekan Run side thence down
the same to the Beginning Tree of afsd. Pricherds Tract, thence
South Fifty five Degrees West, one Hundred and Ten Poles, to the
afsd. Beginning Elm Tree, containing by Estimation one hundred
acres of land be it more or less. Provided there should be no Heirs
Male or Female of my said Son or Sons (Hereafter named) Live to
arise to the age of Twenty one Years, that then after the Decease of
my s'd son or sons afsd. or their Heirs, that then their part of Land
to be equally Divided amongst the rest of my Surviving Devisees 3**
hereafter mentioned. Furthermore I also give Unto my s'd son
Abraham Van Meter on Certain Tract of Land being and Situate on
Opequon Run in the County afrs'd and to his Heirs Lawfully Begotton
being part of Four hundred and Seventy five acres of Land Bought of
Jpst^Hite, Beginning at or about two yards below a Pine Tree on a
high Bank on Opeckon Run called the Allaji Hill, and running thence
by a Division Line North Sixty five Degrees""East sixty Polls, to a
small Hickory thence North Twenty Degrees West Twenty Eight Poles
31
 THE VAN METRE GENEALOGY to a Black Oak then North
Twenty Degrees West Sixteen Poles then North Fifteen Degrees East
two hundred and nine Poles to a Spannish Oak another corner of the
Original survey Thence North twenty Degrees West sixteen Poles to
the First Beginning head of the survey of the original Tract by
Opeckon Run side near a White Oak marked thus IVM, then up
Opeckon Run to the Beginning Pine, containing by estimation Two
hundred and thirty seven acres of Land be it more or less &c. the
same I also Give Devise and Bequeath to him my son Abraham and
his Heir Lawfully Begotten, Under the same Restrictions and
Limitations as I have Bequeathed unto him the above mentioned
Land Bought of Francis Pricher, also I Give Devise unto my said son
Abraham (a son of my wife aforesaid thirds of my Movable Estate
and Legacies are paid) an equal proportioned. Childs' part therefrom
as well as Lands to be Disposed of if any there be as of all things
else &c. Fourth I also Will, Give Devise and Bequeath unto my son
Abraham Van Metre and to his lawful Heirs the Southernmost part
and half moiety of four hundred acres of land for me and in my
name to survey for him his Heirs afrs'd which land I have Jos Hite's
Bond for procuring a Pattent, which if he shall not obtain the said
Pattent he is to have the said Bond for Recovering so much as will
amount to his share or Proportion according to his dividend of s'd
Tract and the same Land to be held and enjoyed by him under the
same Restrictions and Limitations as the above mentioned Land
Namely the Land Bought of Francis Pricher &c. Fifth, I Devise Will
and Bequeath unto my son Isaac Van Meter and his Heirs Lawfully
Begotten one Part or Tract of Land being part of the Tract of Land
whereon I now Dwell, Beginning at a Bounded stake at the end of
Sixteen Poles in the first Line of the Original Tract Running thence
with the said Line South Thirty Degrees West Sixty full perches, then
South Eighty one Degrees East One hundred and Eighty Eight
Perches, the North Five Degrees East Ten Poles then South Eighty
one Degrees East One hundred and Eighty Poles until it intersects
the line of the Intire Tract then North one hundred Poles to two
white oaks at corner of the Intire Tract then North Fifty two Degrees
West Fifty Poles to a Black Oak another Corner of the Intire Tract
then North Eighteen Poles then South Seventy-six Degrees West to
the Beginning Stake, containing by computation Two hundred and
Fifty acres of Land be it more or less. Provided the said Isaac Van
Meter make sale of the Land he has at Monocacy and deliver one
fourth part of the price thereof to his Brother Jacob and the other
three fourths to be either applied toward improving the Land herein
Bequeathed otherwise laid out in other Lands and the s'd. to be held
under the same Restrictions and Limitations, as those lands Will and
Bequeathed, to my son Abraham as aforementioned. Also I Give and
Devise unto my said son , Isaac Van Meter after my afs'd wife's
thirds of my Movable Estate and Legacies are paid an Equal
proportional Child's part arising therefrom as well of my Lands which
arc to be Disposed of if any there be as of all also my Movables &c.
Sixth Item, I Give Devise and Bequeath unto my son Henry Van
Meter his Heirs Lawfully Begotten one certain Parcel Tract of Land
situate and being in Frederich County on Opeckon Run whereon the
said Henry now dwells. Beginning at the Spannish oak standing by
Opeckon at a Lick in the Branch of s'd Run and running thence into
the woods East Twenty Poles to a Black Oak thence South Eighty
three Degrees East Ninty two Poles to a White Oak then East one
hundred and fifty one Poles to a Hickory in a Line of the original
survey thence down the same to a Run that falls into Opeckon Run
thence down the same into Opeckon Run where a Spring is at the
mouth thereof then up Opcckan Run to the Beginning Spannish Oak
containing by estimation about four Hundred acres of Land be it
more or less, with Liberty to such as possessed the 32
 WILL OF JOHN VAN METRE land below the mouth of the
said Run to get the water and have and possess part of the said
Spring at the mouth of said Run, and hold and enjoy the said land
under the same Restrictions and Limitations as my son Abraham and
his Heirs &c. and if my said son should decease before his wife Eve.
. . . Also I give and Devise unto my said son Henry after my
aforesaid wives third of my Movable Estate and Legacies are paid an
equal proportional Child's part arising therefrom as well as my lands
which are to be disposed of if any there be as of all else &c. Seventh
— Item I will Devise Give and Bequeath unto my son Jacob Van
Metre and his Heirs Lawfully Begotten, one piece or tract of land,
being part of Tract whereon I now dwell. Beginning at a Bound
Hickory standing at the end of the Eighty Poles in the first Line of
the Original and running thence with the said Line North Thirty
Degrees West Fifty six Poles then South seventy one Degrees East
two hundred and twenty four Poles then North sixty six Degrees East
Twenty four Poles then North Eighty two Degrees East Eighty Poles
then North Eighty five Degrees East one hundred and Forty Poles
then North fifteen Degrees west twelve Poles to a Black Oak being
one of the corner trees of the original Tract then North Forty two
Degrees West Eighty two Poles to a Hickory then North sixty eight
Poles until it intersects Isaac Van Meter's Line thence traversing the
several Courses of the said Isaac's Line to the Beginning Containing
by estimation two hundred and thirty three acres of Land with that
part of the Plantation whereon I now dwell together with all the
Houses, Orchards on the said part Parcel, Tract of Land excepting as
before excepted unto my wife to hold and enjoy the same tinder the
same Restrictions and Limitations as is aforementioned unto my son
Abraham and his Heirs &c. Also I give Devise and bequeath unto my
said son Jacob after my wifes Third part of my Movable Estate and
Legacies are paid an equal proportional Child's part arising therefrom
as well as my lands which are to be disposed of if any there be as of
all else &c. Eighth, Item, I will Devise give and Bequeath unto the
Heirs Begotten [on] the body of my daughter Sarah wife to James
Davis, one Piece or Tract of Land, part of the Tract of land whereon I
now dwell Beginning for the same at the first Beginning Tree of the
Intire tract and Running thence South Thirty degrees West Sixteen
Poles to a stake then North Seventy-five Degrees East two hundred
and ninty two Poles to a cross the Intire Tract then around the
several courses Joining Rebeccas land to the Beginning Containing
by computation two hundred and Twenty acres of Land, more or less
to be held under the same Restrictions, Titles, Limitations as
aforesaid. Also, I give and Bequeath unto my said Daughter after my
said wife's Thirds of my Moveable Estate and Legacies are paid an
equal proportional Child's part arising therefrom as well of my Lands
wh are to be Disposed of if there be of all else. Provided, and it is
my Soul Intent and Meaning that James Davis together with his wife
Sarah give Good and sufficient security unto my Executors, for the
sum of her Proportional part of my Moveable Estate arising to be
paid unto their Heirs, equally divided amongst them when they shall
arrive at the age of twenty one years, and on Refusal of such
security the Proportional part so arising to remain in the hands of my
Executors until the Heirs aforesaid arrive at the age aforesaid &c.
Nintjj^ Item, I will Devise Give and Bequeath unto my daughter
Mary. wiTeoi Robert 7 nnr': and to the Heirs of her^ body Law fujiy
Bfifixtttip one certain piece or Tract of Land J)eing~paiT
oF^theTTract whereon I now Dwell beginning at a large White Oak
by a Hole in the Ground it being a corner of the original Survey of
the Whole Intire Tract and JRunning from the said oak South twenty
one Degrees West two hundred 4 23
 THE VAN METRE GENEALOGY and eight Poles then South
forty two degrees west forty two Poles to a White Oak by a Mead on
a corner of the Original Tract thence South forty two Degrees East
Sixty Poles thence North Fifty four Degrees East three hundred and
forty Poles until it Intersects the Line of the Intire Tract then with the
same eighteen Degrees East Sixty five Poles to a Hickory Corner of
the Original Tract thence North Thirty Degrees East eighty poles to
the afs White Oak by Spring it being another Corner of the Original
Tract then North Fifteen Degrees West Seventy Poles thence South
Eighty three Degrees West Eighty Poles to a Black Oak then South
ten Degrees West Fifty six Poles to a stake by a corner of a fence
then East by the said fence to another stake then thirty Degrees
then West one hundred and sixty four Poles to another stake then
Northwest sixty six Poles to the Beginning containing by estimation
three hundred and fifty acres of Land be it more less the same to be
held and enjoyed under the same Restrictions and Limitations above
mentioned in the Lands Willed and Bequeathed to my son Abraham
Van Metre and his Heirs &c. Also, I give and Devise unto my said
Daught^^Mary ^ife to the said Robert Jnnps after my afsd Wife's
ThirHT^oT^'my Movable Estate and Legacies are paid an Equal
Proportional Child's part arising therefrom as well of my Lands which
are not to be disposed of if any there be as of all else, Provided, and
it is my Soul Intent and meaning that Robert Jones With his wife
Mary give Good and sufficient security unto my Executors for the
sum of her proportional part of my Movable Estate, arising to be
jjaid unto their Heirs equally divided arnongst them when^ they
arrive to the_age of Twenty one years, and on Refusal of suich
security, the Proportional part scT arisingTo remain in the hands of
my Executors until the Heirs afs*^ arrive af^**. Tenth, Item, I
Devise Give and Bequeath unto my Daughter Rebecca wife to
Solomon Hedges, Esq., and to her Heirs Lawfully Begotten of her
body one parcel or Tract of land being part of the tract I now Dwell
on Beginning at a corner marked Black Oak the lower most corner
on the east side of the meadow and running with the lines of the
Original Tract North Thirty three Degrees West One hundred & ten
Poles to a Black oak then South Seventeen Degrees West one
hundred and Fifty eight Poles to a Hickory then South Sixty Degrees
West and Ninty five Poles to a Black Oak then South Fifteen Degrees
West one hundred and thirty six Poles and in a corner of the other
Tract then crossing the said Tract North seventy nine Degrees East
one hundred and sixty Poles until it shall intersect the Line of the
Intire survey then with the same North Twenty five Degrees East
two hundred and forty four Poles to the Beginning Black Oak
containing by estimation two hundred acres of Land and meadow be
it more or less to be held and enjoyed by the Heirs of the said
Solomon and Rebecca Lawfully begotten of her body under the same
Restriction and Limitations as is mentioned to Abraham Van Meter's
Heirs, &c. Also I give and devise unto my said Daughter Rebecca
after my said wife's Thirds of my Movable Estate and Legacies are
paid an Equal Proportional Child's part arising therefrom as well as of
my Lands which are to be disposed of if any then be as of all else,
&c. Provided, and it is my soul Intent and meaning that Solomon
Hedges and Rebecca his wife give Good and sufficient security unto
my Executor's for the sum of her Proportional Part of my Movable
Estate arising to be paid unto their Heirs Equally Divided amongst
them when they shall arrive to the age of Twenty one years and on
Refusal of such Security, the Proportional part so arising to remain in
the hands of my Executors until the Heirs afs" arrive at the age afs"
&c. Eleventh, Item, I give Devise and Bequeath unto my Daughter
Elisabeth Wife to Thomas Shepherd and to the heirs of her body
Lawfully Begotten 34
 WILL OF JOHN VAN METRE One Certain Tract or piece of
Land being part of the Tract whereon I now dwell beginning at the
South corner of the above Devised Land and running thence with
the same North Fifty four Degrees East Three hundred and Forty
Poles until it shall Intersect the Line of the Intire Tract thence
Traversing the Lines of the Intire Tract round to the Beginning,
containing by computation three hundred acres of Land. Also one
other Tract of Land Lying situate and being in Prince George's
County in the Province of Maryland known by the name of Pelmel.
Beginning at a bounded Ash standing at the upper end of a Tract of
land called Antetum Bottom on the Bank of Potomack River
containing one hundred and sixty acres of Land according to the
Certificate of Survey under the same Title Restrictions and
Limitations as in afs" Bequest and Devise unto my son Abraham Van
Meter and his Heirs. Also if Robert Jones should be scarce of Water
or his Heirs, or anyother the Devises or their Heirs into whose Hands
the Lands shall come into, then it shall and may be Lawful for them
to Digg a Trench to Convey the Water from the Run into the said
Land with [out] Interruption of him the said Thomas Shepherd or his
heirs afore^*'*. Also I give and Devise unto my said Daughter
Elisabeth wife to Thomas Shepherd after my afs* wife's Thirds of my
Movable Estate and Legacies are paid an equal Proportional Child's
part arising therefrom as well of my Lands which are to be Deposed
of if any there be as of all else &c. Provided, and it is my Soul Intent
and meaning that Thomas Shepherd and Elizabeth his wife Give
Good and sufficient security unto my Executors for the sum of her
proportional part of my movable Estate arising to be paid unto their
Heirs equally Divided amongst them when they shall arrive at the
age of Twenty one Years, And on Refusal of such security the
Proportional part so arising to Remain in the Hands of my Executors
until the Heirs afs* arrive at the age afsd &c. Twelvth, Item, I Devise
Give and Bequeath unto my Daughter Magdalena the sum of twenty
shillings, as her full Legacy whereby when paid or tendered to her
by my Executors is discharged and fully acquitted from any Right
Title or Interest or in or to my Real or Personal Estate and I do
Devise Will and Bequeath unto her Heirs Lawfully Begotten on her
body a Certain Tract or piece of Land being part of the Tract
whereon I now Dwell beginning at a marked Red Oak saplin being a
corner of the original survey of the Intire Tract and Running thence
North Thirty Degrees East Twelve Poles, then South Seventy one
Degrees East two hundred and twenty four Poles then North sixty six
Degrees East twenty four Poles then North Eighty two Degrees East
Eighty four Poles then south Eighty Poles then south ten West fifty
six Poles then East twenty Poles then North West sixtysix Poles to a
white oak by a Hole being a corner of the survey of the Intire Tract
then with the Line of the same to the beginning Black oak saplin
Containing by estimation two hundred and fifty acres of land be it
more or less to be held and enjoyed by the heirs of my said
Daughter under the Limitations and Restrictions according to the
Devise made to my son Abraham van Meter's Heirs, &c. Also I give
and Devise unto the Heirs of my said Daughter Magdalena after my
wife's Thirds of my Movable Estate so arising to remain in the hands
of my Executors until her heirs arrive to the age of Twenty one years
and then equally between them and for want of such Heirs to be
equally divided amongst the other Devisees &c. Thirteenth Item, I
will Devise Give and Bequeath to the son of Daughter Rachael
deceased (viz) John Leforge a certain tract of land containing two
hundred acres being part of four hundred acres of land which my
son Abraham Van Meter hath Divided to him, which two hundred
acres of Land are to be held and enjoyed under the same
Restrictions and Limi3b
 THE VAN METRE GENEALOGY tations and Tntails as
aforementioned &c. as also two Breeding Mares, and if it so happen
that he should die that then the said mares shall be given to his two
cousins namely Johannes Van Meter son of Johanes Van Meter
deceased and Joana daughter of the said Johanes deceased &c.
Fourteenth, Item, I will Devise and Bequeath unto my Grandson
Johannes Van Meter son of my Eldest son Johannes Van Meter
Deceased and to his Heirs Lawfully Begotten a certain parcel of Land
being the uppermost part of the afs** four hundred and seventy five
acres of land which I purchased of lost Hite Beginning at the afs**
Pine Trees mentioned in the second clause of my Bequest to my son
Abraham Van Meter out of part of the same Tract and running
thence with the same Division Line Between him and my son
Abraham North sixty Degrees East sixty Poles to a small Hickory
Saplin standing on the Line of the Survey of the whole Intire Tract
then with the same South twenty three Degrees East two hundred
and Fifty seven Poles to a White oak standing at a corner of the
original survey and is the uppermost corner of the Land mentioned
in Jost Hite's Deed then running with the Line of the said Deed to
Opeckon Run and Down the same to the afs'* Pine Tree containing
by estimation two hundred and thirty eight acres be it more or less.
Provided the said Johanas Delivers an equal share of his Land at
Monokasy or the value thereof to his sister Joana Daughter of
Johannes Van Meter Deceased, then this Land Willed and
Bequeathed to my Grand son Johannes Van Meter is to be held by
him Under the same Restrictions and Limitations as aforementioned
in Abraham's Bequest, Also I will that my said grandson Johannas
have two Breeding Mares, &c. Fifteenth, Item. I will that if any veins
or any sort of mines should at anytime hereafter be Discovered on
any part of my Lands herein mentioned, Given Willed Devised and
Bequeathed, and that the same should arise amount or become of
more value than Fifty Pounds that then such Mines to be equally
divided amongst my Devisees and every of them to have equal share
or proportion of the same with Liberty of Roads to and from the
same for Transporting of such mine also Liberty to Digg and make
search and Trail for such Mines in Co-Partnership with the rest of the
Devisees, &c. Sixteenth, Item, I also Will Devise Give and Bequeath
the sum of Ten Pounds Virginia Money to be paid by my Executors to
my grand-chidren to Johannes Van Meter and Joana Van Meter the
sum of Fifteen Pounds when they arrive to the age of twenty one
years of age. Seventeenth, Item I do nominate. Constitute and
Appoint my son-in-law Thomas Shepherd, Abraham Van Meter and
Jacob Van Meter my sons joint Executors of this my last Will and
Testament Impowering them to act and perform according to what is
contained in every Clause being Contained in five Sheets of Paper
Disannuling and making void all other Wills and Testament's by me
in any wise by me heretofore confirming this and no other as my last
Will and Testament. In Witness Whereof I have hereunto set my
hand and seal the Day and Year above Written. signed John Metor
[seal] Signed sealed Published and Pronounced and Declared by the
said John Van Meter as his last Will and Testament in the Presence
of us : his Edward X Morgan mark Andrew Corn Joseph Carroll.
[Probated at Winchester Va. 3* Sept. 1745]. 30
 DESCENDANTS OF JOHANNES VAN METRE SARAH- VAN
METRE I. Sarah Van Metre (John^), eldest daughter of John Van
Metre, born in Somerset Co., New Jersey, and baptized, according to
the register of the Reformed Dutch Church at Somerville, N. J.
(Records of the Holland Society, New York), on 30 Oct., 1706; died
after 1745; married circa 1725 James Davis (probably of the family
of James Davis of Pilesgrove, Salem Co., N. J. — Pilesgrove Church
Record). A James Davis was killed by the Indians on one of their
raids along the upper Potomac valley, in 1757 (Kercheval's History of
the Valley). By the terms of her father's will Sarah was devised 220
acres of land out of his possessions in Frederick Co., Va., 1745. On
July 9, 1754, James Davis conveys this property to his wife's
youngest brother Jacob Van Metre (Frederick Co., Va., Records).
DESCENDANTS OF JOHANNES VAN METRE II. Johannes Van Metre
(John^), eldest son of John and Sarah (Bodine) Van Metre was born
on the Raritan, in Somerset Co., N. J., and was baptized at
Somerville, N. J., 28 April, 1708 (Records of the Reformed Dutch
Church), died in Alaryland circa 1730; married Rebecca Powelson
who was probably a descendant of Capt. Hendrick Pauelson, several
of whose family were settled along the North Branch of the Raritan,
between 1700-30. John Van Metre having emigrated, circa 1725, to
the Monacocy in Prince George's Co., Maryland, the son Johannes
probably joined him there, after his marriage, accompanied by
several friends and relatives. Here his two children were born:
Johannes, Jr., and Joanna. Religeously venerated family tradition
asserts that Johannes, Jr., was " the first white child born west of the
Blue Ridge." But that statement can hardly be maintained since the
Monacocy settlement is east of the Blue Ridge, unless this child was
born in the valley of Virginia whilst his parents were with John Van
Metre — the grandfather — when he was in Virginia to obtain the
grant of lands from Governor Gooch. However, Johannes Van Metre
remained a colonist in Maryland and probably died in Prince George's
Co., during the prevalence of an epidemic which raged among the
settlers on the Potomac in 1732-33, and which carried off many of
the inhabitants in its fearful ravages. It is said that his widow,
Rebecca, married a son of Jonas Hedges whose wife was Agnes
Powelson, a sister of Rebecca, but these statements are univerified.
Issue: I, Johannes, Jr. ; 2, Joanna. 37
 THE VAN METRE GENEALOGY I. Johannes, Jr. (JohnS
Johannes^), son of Johannes and Rebecca (Powelson) Van Metre
was b. circa 1730; d. circa 1818; tn. 1st Josina Taylor; w. 2d circa
1790, " when in his 60th year,'' a young German woman and by
whom he is said to have had nine children, several of whom were
under age at the date of their father's death. His will does not
mention his wife's name nor allude to her, and the inference is that
he died a widower. During the minority of Johannes and his sister
Joanna they were under the care of their uncle Jonas Hedges and
his wife Angelitje (Agnes). Their grandfather, John Van Metre, named
them among legatees in his will (1745) and gave them personalty in
his Deed of Gift (1744). Some difficulties having arisen in the
distribution of the grandfather's estate, these children appealed to
the Court of Prince George's Co., Md., and by it Jonas Hedges was
appointed their guardian, 7 Oct., 1747. An action in chancery was
taken by their guardian against Abraham and Jacob Van Metre, their
uncles, and executors under the will of John Van Metre. Jonas
Hedges filed his account in Court, as Guardian, in 1751; the wards
having probably attained their majority prior to this time. Johannes
had an estate in Maryland called " Pipe Meadow " ; it probably lay on
Pipe Creek which emptied into the Alonocacy in Price George's Co.
Jointly, with his wife Josina's endorsement thereon, 22 acres of it
was conveyed to Michael Raymer, 5 Aug., 1759. This particular piece
of property was called: "End of Strife" (Book F, p. 837, Frederick Co.,
Md., Records). The original tract called " Pipe Meadow " was
composed of 350 acres ; and the elder Van Metre on July 18, 1745,
had sold 150 acres of it to the above Michael Raymer, under power-
of-attorney running to Baltis Foutz. A further conveyance was made
of the remaining 178 acres which was described as located at the
mouth of Carver's run — by young Van Metre — which did not bear
the wife's endorsement — on 21 June, 1759 (29 Nov., 1759), to
William Burns, the husband of his sister Joanna (Bk. F, p. 899).
Having dispQsed of Pipe Meadow, Johannes removed into Berkeley
Co., Md."(then Frederick Co.), and settled a property on the bank of
the Opequon east of the present town of Martinsburg, W. Va. —
while his sister and her husband, Wm. Burns, located near the
present village of Kearneysville. Jefiferson Co., W. Va. Johannes Van
Metre was very fond of hunting. His death, it is said, was the result
of having thrown himself upon the ground while heated, after one of
these expeditions, thereby contracting pneumonia. His will is
recorded at Martinsburg and was probated 12 Oct., 1818. In it his
land is described as being on the road from Opequon to " Traveler's
Rest," former residence of Gen. Chas. Lee, of the Revolution ; and
that it shall go to his male issue as a " Home in Common for all my
children until the 38
 THE VAN METRE GENEALOGY youngest son attains the age
of 21 years." His son Thornton is to have his dwelHng plantation ;
and the three sons, Ezra, John and Thornton, " shall be chargeable
with the clothing, schooling and support of my daughters :
Catharine, Eliza, Josina, and Marie Van Metre." Then the instrument
goes on to say : " Deeming it improper to hold a human creature in
bondage during life I direct that my negro woman Hannah shall be
emancipated when my son John arrives at age of 21 years, and at
that period my executor pay her the sum of $5.00 for each of my
children as a token for the attention she has shown toward my
family." " Mulatto Mary " is to be emancipated when Thornton comes
to age of 15 years. "All my younger slaves to be emancipated when
they respectively arrive at age of 28 years and that all their
descendants be emancipated when they arrive at same age." John
Alburtis is named as Executor; but by a codicil of later date his
eldest son Ezra is made a co-executor with Alburtis. Issue: 3, Nancy;
4, Ezra; 5, John; 6, Thornton; 7, Catharine; 8, Eliza; 9, Josina; 10,
Marie; and 11, a child d. y. 2. Joanna Van Metre (John^, Johannes-),
dau. of Johannes and Rebecca (Powelson) Van Metre, was born on
the Monocacy, in Prince George's Co., ]\Id., circa 1732. The date of
her birth and death are determined by the inscriptions found upon
her tombstone in the burial plot on the homestead near
Kearneysyille, Jefferson Co., W. Va., which was, until recently, the
property of the late John Baker Kerfott, Esq., one of her
descendants. Joanna died 21 August, 1801," in the 69th year of her
age." She m. William Burns, who was born 1718 and died 31 Dec,
1806. They w^ere both buried, side by side, in the little graveyard
on the Kearneysville farm. The Burn's homestead, originally
containing 350 acres, was granted to William Burns by patent from
Lord Fairfax; and lay on the west side of Opequon Creek. This
property was devised by his will to his grandson William Burns the
eldest son of the testator's son George. In the event of William's
death without issue the property was to pass to William's brother
Joseph. Another property which the testator bought of the Hedges
was bequeathed to testator's daughter Rebecca. It contained 300
acres of land and was situated on the Warm Springs road. The will
also mentions testator's brother : " Robert Burns now of
Pennsylvania " ; Abraham Van Metre, Sr., and the latter's nephew,
Abraham, son of Jacob Van Metre ; and appoints son John Burns
and Abraham Van ^letre, Sr. (his son-in-law), Executors (Book 4, p.
123, Martinsburg Records). Issue: 12, George; 13, WilHam; 14,
John; 15, Robert; 16, Hannah; 17, Ruth; 18, Elizabeth; 19, Mary; 20,
Isabella; 21, Margaret; 22, Rebecca. 39
 DESCENDANTS OF JOHANNES VAN METRE 3. Nancy Van
Metre (John^, Johannes-, Johannes^), dau. of Johannes and Van
Metre, b. 29 June, 1794; d. ; m. circa 1815, John Alburtis, who was
b. 14 May, 1794. Issue: 23, E. G. Alburtis, b. Berkely Co., Va., 6 July,
1817; d. 21 March, 1875; m. 20 Dec, 1842, Mary C. Swartz ; issue, a
son and seven daughters. E. G. Albertis was a captain in the Mexican
War ; was also a captain in the Wise Artillery and as such took part
in the suppression of John Brown's raid upon Harper's Ferry, Va. He
also served in the Civil War, and subsequently became clerk of the
Berkeley Co., Va., Court. (Norris's History, Lower Shenandoah, Va.) 5.
John Van Metre (John^, Johannes^, Johannes^), m. Mary Gorrell. 7,
Catharine Van Metre (John^, Johannes^, Johannes^), in. Pierce —
em. to Ohio. 8. Eliza Van Metre (John^, Johannes^, Johannes^), m.
i, James Russell ; in. 2, William McLean. 9. Josina Van Metre (John\
Johannes-, Johannes^), 7». John E. Van Metre. 10. Marie Van Metre
(John\ Johannes^, Johannes^), m. Abraham E. Van Metre, son of
"Colonel" Isaac Van Metre (IX. 12), which see. 12. George Burns
(John^, Johannes^, Joanna^), son of William and Joanna (Van
Metre) Burns, b. ; d. ; in. 10 July, 1799, at Martinsburg, Berkeley
Co., Va., Agnes, dau. of Joseph and Elizabeth (Rawlings) Hedges.
Issue: 24, William Burns ; 25, Joseph Burns. 13. William Burns
(John\ Johannes-, Joanna^), m. Magdalena Van Metre. 14. John
Burns (John^ Johannes^, Joanna^), m. Fanny South wood.. 15.
Robert Burns (John^, Johannes^, Joanna^), in. Rebecca
Southwood. 16. Hannah Burns (John^ Johannes-, Joanna^), m.
Abraham Van Metre. 17. Ruth Burns (JohnS Johannes^, Joanna^),
m. Daniel Colgin. 18. Elizabeth Burns (John\ Johannes-, Joanna^),
in. Abraham Van Metre. 19. Mary Burns (John^, Johannes^,
Joanna^), in. Isaac Van Metre. 40
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