Clinical features Flashcards
Red Eye DDx
subconjunctival hge: posterior edge
retrobulbar hge: proptosis, restricted movement
episcleritis: mild pain, normal vision
scleritis: more painful
Phlyctenule: nodule
Conjunctivitis: sore, swelling, d/c
Keratitis: rapid LoV, ‘FB’, pain, circumcorneal, hypopyon, constriction
iridocyclitis: blurry, circumcorneal, cells/flare, constriction
PACG: sudden severe loss, pain, fixed dilated, hazy, circumcorneal
dendrictic ulcer
eye sepsis: contact lenses, circumcorneal, gritty pain
Gradual Loss of Vision DDx
cataracts: cloudy
glaucoma: cupping
corneal dystrophy/ectasia (thinning/keratoconus)
macula: AMD, dystrophy, CSMO
optic disc: compression, toxins
retinitis pigmentosa: spicules
Acute Painless Loss of Vision DDx
monocular:
- corneal disease: painful, cloudy
- anterior chamber (hyphaemia)
- vitreous hge
- AION: pale disc
- retinal: a/v occlusion, detachment, macula hge
binocular
- optic chiasm: pituitary
- optic nerve: infiltration, papilloedema, neuritis
- cortical: CVA, migraine
Diabetic Retinopathy
NPDR:
- microaneurysms
- exudates
- hge/CWS
- dilatation, beading, and IRMA
PDR:
- NVD or NVE
- tufts and ramifications
- pre-retinal/vitreous hge; detachment (traction)
maculopathy:
- focal: local thickening, ma/dilated, exudate
- diffuse: diffuse oedema, no exudate
- ischaemic: oedema, dark hge; angiography
Visual Field Defects
whole eye: neuritis/AION, glaucoma, optic atrophy, papilloedema, detachment, CRVO, hge
bitemp hemi: chiasm - aneurysm/tumour
homo hemi: strokes; optic tract/cortex
scotoma: glaucoma, AMD, neuritis, papilloedema, atrophy
peripheral: glaucoma, RP, hysteria
altitudinal: BRVO/BRAO, AION
Dilated Pupil
Holmes-Adie: reflexes; viral; vermiform; LND
CN III palsy: ptosis, ‘down and out’; med/surg
Drugs/poisons: atropine, CO, antifreeze, tropicomide
trauma
Constricted Pupil
Horner’s: SANS
Argyll Robertson: syphilis
Drugs/poisons: opiates, organophosphates, pilocarpine
CN Palsies
0 = full movement; 1 = 75% movement; 2 = 50%; 3 = 25%; 4 = no movement
III: down-and-out ptosis (hypoesotropia), near/reading worse; tumour, aneurysm, trauma, inflammation (BM/HTN)
IV: sits higher (hypertropia + excyclotorsion); head tilt/vertical diplopia, near worse; trauma, vascular (DM/HTN/CVA); congenital
VI: esotropia; distance worse; horizontal gaze defect/diplopia; tumour, ICP/IOP, MG/MS, vascular
VII: open eye, facial mm
Cataract Types
cortical: radial spokes; worse dark;
nuclear: central; yellow; myopia, distance worse
post. subcap: near worse reading/glare/central
age-related and congenital DM: snowflake, osmotic hydration Trauma: rosette atopic dermatitis: stellate other: infection, toxins, systemic disease
Glaucoma Types
POAG: cupping, atrophy, blurry’ VF (tunnel) aSx
PACG: pain, N&V, blurry vision; fixed mid-dilated pupil, cloudy, red eye; acute LoV, cupping, atrophy
Rubeotic: CRVO/DR; rare; neovasc
Trauma Types
foreign body: photophobia, irritation chemical: clouding blunt: hyphaema, subconj hge, haematoma blow-out fracture penetrating corneal laceration
Optic Disc Swelling DDx
papilloedema: bilateral, blurry, hge/exudate/cws
neuritis: blurry, normal colour, move pain, red desat, (R)APD; 45-80% MS
malignant HTN: silver wiring, nipping, hge, exudate
AAION: Sx, pale, blurred, n/large cup
NAION: hyperaemia, small cup
atrophy: pale, flat, sharp, loss of BV, RAPD
diabetic papillopathy: progressive VFD, colour vision, ?RAPD, uni or bilateral
Optic Disc Atrophy DDx
pale disc + APD + LOV
blood supply: ischaemia, AION
compression: tumours, glaucoma
neuritis
AMD
dry (atrophic)
- atrophy: receptor death
- drusen (Bruch’s membrane)
wet (neovascular):
- fragile BV leak/scar
- distortion (grid lines)
Correcting Refraction/Squint
hypermetropic (distance; short/weak): convergent (positive) lenses
myopic (near; long/strong): divergent (negative) lenses
squint:
- glasses: refraction + align
- cataract removal
- occlusion: patch/atropine; 6h/d for 10/52
- surgery: functional/cosmetic
Orbital Diseases
more detail needed on some
thyroid eye disease: Sx
orbital cellulitis: systemic
Idopathic orbital inflammatory disease (IOID): chemosis, plegia, pain
vascular: varicies, fistula; proptosis, bruit
capillary/cavernous haemangioma: cough/strain
lacrimal gland tumours: painless/slow vs. painful/fast
glioma: young girls, NF1, GLoV
meningioma: middle-age F, GLoV
Thyroid Eye Disease
eyelid lag/retraction, exposure keratopathy periorbital oedema, exophthalmos compressed optic nerve/neuropathy restrictive myopathy and diplopia Rx: radiation/drugs for thyroid
Orbital Cellulitis
acute; sight and life-threat - abscess, meno, CS thrombosis
infection behind septum
malaise, fever, orbital signs (plegia, soft tissue, vision, pain, en/exophth)
Rx: Ax, ABx, ?surgery
IOID
pseudotumour: non-neo, non-infectious; 20s-50s
Dx of exclusion
unilateral, proptosis, chemosis, oedema, plegia, acute, pain
Rx: anti-inflamm (NSAIDs, steroids, cytotoxic)
Conjunctivitis
revise viral/bact/allergic
gritty pain: follicules (viral), papillae/cobbles (allergic)
watery/mucopus d/c, diffuse redness
Rx: lubrication, hygiene, cold compress, ?chloramphenicol
Uveitis
achy, photophobia, diffuse and circumcorneal redness
mid-constricted (oval) pupil, posterior synichae
cells and flare (WCC)
inflammatory causes (IBD, sarcoid, Reiter’s, arthropathy)
Rx: eye casualty; dilate, steroids
red eye - Haemorrhages
subconjunctival: aSx, sectoral, posterior margin
- BP spike, rubbing, post-op
- Rx: reassurance, ?#, ?BP
retrobulbar: homogenous red, no edge, plegia, IOP, proptosis
- iatrogenic, trauma
- Rx: referral (risk of nerve compression)
Artery Occlusion
branch: sectoral/central; RAPD, bruit, VFD, emboli, nipping, flame hge
- BP, carotid doppler, blood, echo
- Rx: casualty referral
central: total light blindness, ‘shutter’; ADP/RAPD; oedema, cherry red spot, emboli, bruit
- temporary loss Hx, dopplers, BP, ESR, echo
- Rx: CO2, massage, acetazolamide + paracentesis, casualty ref
Vein Occlusion
‘on waking’
branch: central blur, on waking; sectoral hge and CWS
- BP, ESR, FBC, BM
- Rx: collaterals = recovery
central: global defect on waking; may have RAPD; flame hge, CWS, oedema, disc swelling, neovasc
- BP, blood, IOP; 30% ischaemic - angiogram
- Rx: PRP (rubeosis risk)
Retinal detachment
floaters, flashes, VF loss; ?RAPD, red reflex lost
tractional: PDR
Rhegmatous: tear
Exudative: uveitis, tumours
Rx: laser pexy, vitrectomy, gas tamponade
anterior ischaemic optic neuropathy (AION)
arteritic: temporal aa; jaw claudication, scalp pain; atrophy, swelling
non-artertitic: atheroma/occlusion and ischaemia
Vitreous Haemorrhage
PDR/neovasc common;
retinal tears
posterior vitreous detachment
trauma
cloudy fundoscopy, no red reflex, floaters
B Scan USS
Rx spontaneous resorption vs. removal
optic neuritis
45-80% MS
60% normal disc, 25% papillitis, 18% blurred/pale disc
unilateral visual loss, pain on movement, red desaturation, (r)APD
systemic diseases
vasculitis:
- SLE: conjunctivitis, episcleritis
- Reiters: conjunctivitis and/or uveitis
- PAN: episcleritis
- RhA: scleritis
- ankylosing spondylitis: uveitis
metabolic
granuloma
vascular retinopathy: HTN, emboli, haemorrhage
visual impairment causes
Aids: magnifiers, binocular, strong glasses, talking devices
kids: 5% of LVA patients are
amblyopia causes
Rx: correct refraction, occlusion, surgery
stimulus deprivation: cataracts, tumour, ptosis, cornea etc.
strabismus (squint)
anisometropic: >1D difference in refraction; higher error eye suppressed
CN Palsy DDx
neurogenic: trauma, tumour, microvasc
- microvasc most common; pupil spared; DM/HTN
- inflammatory, infection, demyelination (neuritis; CN VI)
mechanical restriction:
blow out fracture (floor): elevation and depression
thyroid eye disease: elevation worst
myogenic:
MG: intermittent, fatigue, LPS worst
tumour/inflammation/mm disease
