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Wills Eye Manual > DDx of Ocular Signs > Flashcards

DDx of Ocular Signs Flashcards

1
Q

DDx of Hyphema

A

traumatic, iatrogenic (eg. intraocular surgery or laser), iris neovascularization, herpes simplex or zoster iridocyclitis, blood dyscrasia or clotting disorder (eg. hemophilia), anticoagulation, Fuchs heterochromic iridocyclitis, intraocular tumor (eg. juvenile xanthogranuloma, retinoblastoma, angioma)

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2
Q

DDx of Hypopyon

A

Infectious K ulcer, endophthalmitis, severe iridocyclitis (eg. HLA-B27 associated, Behcet disease), reaction to an intraocular lens (sterile hypopyon), retained lens particle, device contaminant after cataract surgery (toxic anterior segment syndrome), intraocular tumor necrosis (eg. pseudohypopyon from Rb), retained intraocular foreign body, tight contact lens, chronic K edema with ruptured bullae, severe infalmmatory rxn from a recurrent corneal erosion, Drugs (eg. Rifampin).

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3
Q

DDx of Blood in Canal of Schlemm on Gonioscopy

A

Compression of episcleral vessels by gonioprism (iatrogenic), Sturge-Weber syndrome, AV fistula (carotid-cavernous sinus fistula (c-c fistula)), superior vena cava obstruction, hypotony

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4
Q

DDx for conjunctival swelling (chemosis)

A

Allergy, any ocular or periocular inflammation, post-operative, drugs, venous congestion (eg. c-c fistula), angioneurotic edema, myxedema

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5
Q

DDx for conjunctival dryness (xerosis)

A

Vitamin A deficiency, postcicatricial conjunctivitis, SJS, ocular cicatricial pemphigoid, exposure (eg. lagophthalmos, absent blink reflex, proptosis), radiation, chronic dacryoadenitis, Sjogren syndrome

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6
Q

DDx of Congenital Corneal Edema

A

Congenital glaucoma, congenital hereditary endothelial dystrophy, posterior polymorphous corneal dystrophy (PPMD), birth trauma (foreceps injury)

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7
Q

DDx of Acquired Corneal Edema

A

Postoperative edema, aphakic or pseudophakic bullous keratopathy, Fuchs endothelial dystrophy, CL overwear, traumatic, exposure-related, chemical injury, acute increase in IOP (angle-closure glaucoma), K hydrops (decompensated Keratoconus), Herpes simplex or zoster keratitis, iritis, failed K graft, ICE syndrome, PPMD

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8
Q

DDx of dilated episcleral vessels (without ocular irritation or pain)

A

underlying uveal neoplasm, AV fistula (eg. c-c fistula), polycythemia vera, leukemia, ophthalmic vein or cavernous sinus thrombosis, extravascular blockage of ophthalmic/orbital venous outflow

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9
Q

DDx of enlarged K nerves?

A

Most Imp: MEN IIB (medullary carcinoma of thyroid, pheochromocytoma, mucosal neuromas, may have marfanoid habitus)
- acanthamoeba keratitis, chronic keratitis, keratoconus, neurofibromatosis, Fuchs endothelial dystrophy, Refsum syndrome, trauma, congenital glaucoma, failed K graft, Leprosy, ichthyosis, idiopathic, normal variant

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10
Q

DDx of membranous conjunctivitis? (membrane removal is difficult and causes bleeding)

A

Streptococci, pneumococci, chemical burn, ligneous conjunctivitis, Corynebacterium diphtheriae, HSV, ocular vaccinia

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11
Q

DDx of pseudomembranous conjunctivitis? (membrane removal is easy and without bleeding)

A

DDx includes causes of membranous conjunctivitis as well as:
Adenovirus (rarely causes true membrane formation), ocular cicatricial pemphigoid, SJS, SLK, gonococci, staphylococci, chlamydia in newborns

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12
Q

DDx of Opacification of the Cornea in Infancy

A

Congenital glaucoma, birth trauma (foreceps injury), congenital hereditary endothelial or stromal dystrophy (bilateral), PPMD, developmental abnormality of anterior segment (eg. Peters anomaly), metabolic abnormalities (bilateral; eg. mucopolysaccharidoses, mucolipidoses), interstitial keratitis, HSV, K ulcer, K dermoid, sclerocornea

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13
Q

DDx of Pannus (superficial vascular invasion of the cornea)

A

Ocular rosacea, tight contact lens or CL overwear, phlyctenule, chlamydia (trachoma and inclusion conjunctivitis), SLK (micropannus only), staphylococcal hypersensitivity, vernal keratoconjunctivitis, HSV or zoster, chemical burn, ocular cicatricial pemphigoid, aniridia, molluscum contagiosum, leprosy

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14
Q

DDx of pigmentation/discoloration of the conjunctiva

A

Racial melanosis (perilimbal), nevus, primary acquired melanosis, melanoma, ocular and oculodermal melanocytosis (congenital, blue-gray), Addison disease, pregnancy, radiation, jaundice, resolving subconj hemorrhage, conjunctival or subconj FB, pharmacologic (eg. chlorpromazine, topical epinephrine), cosmetic (eg. mascara/makeup deposits, tattoo)

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15
Q

DDx of symblepharon (fusion of palpebral and bulbar conjunctiva)

A

ocular cicatricial pemphigoid, SJS, chemical burn, trauma, drugs, long-standing conjunctival or episcleral inflammation, EKC, atopic conjunctivitis, radiation, congenital, iatrogenic (post-surgical)

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16
Q

DDx of Whorl-like opacity in the corneal epithelium (Verticillata)

A

Amiodarone, chloroquine, Fabry disease and carrier state, phenothiazines, indomethacin

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17
Q

DDx of Bull’s-Eye Macular Lesion

A

ARMD, Stargardt disease or fundus flavimaculatus, albinism, cone dystrophy, rod-cone dystrophy, chloroquine or hydroxychloroquine retinopathy, adult-onset foveomacular vitelliform dystrophy, Spielmeyer-Vogt syndrome, central areolar choroidal dystrophy

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18
Q

DDx of choroidal folds

A

Orbital or choroidal tumor, idiopathic orbital inflammatory syndrome, thyroid eye disease, posterior scleritis, hypotony, retinal detachment, marked hyperopia, scleral laceration, papilledema, postoperative

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19
Q

DDx of choroidal neovascularization (gray-green membrane or blood seen deep to the retina) - More Common

A

ARMD, ocular histoplasmosis syndrome, high myopia, idiopathic polypoidal choroidal vasculopathy, angioid streaks, choroidal rupture (trauma)

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20
Q

DDx of choroidal neovascularization (gray-green membrane or blood seen deep to the retina) - Less Common

A

Drusen of the optic nerve head, tumors, retinal scarring after laser photocoagulation, posterior uveitis (eg. VKH, MFC, serpiginous choroiditis), idiopathic

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21
Q

DDx for retinal arterial embolus

A
  • Platelet-fibrin (dull gray and elongated): carotid disease, less commonly cardiac
  • Cholesterol (sparkling yellow, usually at an arterial bifurcation): Carotid disease
  • Calcium (dull white, typically around or on the disc): cardiac disease
  • Cardiac myxoma (common in young patients, particularly in the left eye; often occludes the ophthalmic or CRA and is not seen)
  • Talc and cornstarch (small yellow-white glistening particles in macular arterioles; may produce peripheral retinal neovascularization): IV drug abuse
  • Lipid or Air (CWS, not emboli are often seen): results from chest trauma (Purtscher retinopathy) and fx of long bones
  • Others: tumors, parasites, other FB
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22
Q

DDx for Macular exudates

A

More Common: Diabetes, choroidal (subretinal) neovascular membrane, HTN

Less Common: Macroaneurysm, Coats disease (children), peripheral retinal capillary hemangioma, retinal vein occlusion, papilledema, radiation retinopathy

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23
Q

DDx for normal fundus in the presence of decreased vision

A

Retrobulbar optic neuritis, cone degeneration, Stargardt dz or fundus flavimaculatus, other optic neuropathy (eg. Leber hereditary optic neuropathy, tumor, alcohol, or tobacco), rod monochromatism, amblyopia, CAR, MAR, nonphysiologic visual loss

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24
Q

DDx for optociliary shunt vessels on the disc (AKA retinochoroidal shunt vessels)

A

Orbital or intracranial tumor (esp. meningioma), prior CRVO, chronic papilledema (eg. pseudotumor cerebri), chronic open angle glaucoma, optic nerve glioma

25
Q

DDx of Posterior pole retinal neovascularization

A

Diabetes, prior CRVO

26
Q

DDx of peripheral retinal neovascularization

A

Sickle cell retinopathy, prior BRVO, diabetes, sarcoidosis, syphilis, OIS (carotid occlusive dz), pars planitis, Coats disease, ROP, embolization from IV drug abuse (talc retinopathy), chronic uveitis, others (leukemia, anemia, Eales disease, familial exudative vitreoretinopathy)

27
Q

DDx of Roth Spots (Retinal Hemorrhages with white centers)

A

MC: Diabetes, Leukemia, septic chorioretinitis (2/2 bacterial endocarditis

Less Common: Pernicious anemia, SSA, scurvy, SLE, connective tissue dz

28
Q

DDx of Sheathing of retinal veins (periphlebitis)

A

MC: Syphilis, sarcoidosis, pars planitis, Sickle cell disease

LC: TB, MS, Eales disease, viral retinitis (HIV, herpes), Behcet disease, fungal retinitis, bacteremia

29
Q

DDx of decreased IOP (hypotony)

A

Ruptured globe, phthisis bulbi, retinal/choroidal detachment, iridocyclitis, severe dehydration, cyclodialysis cleft, ocular ischemia, drugs (glaucoma meds), post-operative, traumatic ciliary body shutdown

30
Q

DDx of Iris Heterochromia - Involved iris is lighter than normal

A

Congenital Horner syndrome, most cases of Fuchs heterochromic iridocycltitis, chronic uveitis, juvenile xanthogranuloma, metastatic carcinoma, Waardenburg syndrome

31
Q

DDx of Iris Heterochromia - Involved iris is darker than normal

A

Ocular melanocytosis or oculodermal melanocytosis, hemosiderosis, siderosis, retained IOFB, ocular malignant melanoma, diffuse iris nevus, retinoblastoma, leukemia, lymphoma, ICE syndrome, some cases of Fuchs heterochromic iridocyclitis

32
Q

DDx of Melanotic (brown) iris lesion

A

Nevus, Melanoma, adenoma, adenocarcinoma of the iris pigment epithelium

Cysts, FBs, neurofibromas and other lesions may appear pigmented in heavily pigmented irides.

33
Q

DDx of Amelanotic (white, yellow or orange) iris lesion

A

amelanotic melanoma, inflammatory nodule or granuloma (eg. sarcoid, TB, leprosy, other granulomatous dz), neurofibroma, patchy hyperemia of syphilis, JXG, medulloepithelioma, FB, cyst, leiomyoma, seeding from posterior segment tumor

34
Q

DDx of Neovascularization of the Iris

A

Diabetic retinopathy, OIS, after CRVO/BRVO or CRAO/BRAO, chronic uveitis, chronic RD, intraocular tumor (eg. RB, melanoma), other retinal vascular dz

35
Q

DDx of Iridescent Lens particles

A

Drugs, Hypocalcemia, myotonic dystrophy, hypothyroidism, familial, idiopathic

36
Q

DDx of Anterior Lenticonus (marked convexity of anterior lens)

A 
Alport syndrome (hereditary nephritis)
AL - ALport
37
Q

DDx of Posterior Lenticonus (marked concavity of posterior lens surface)

A

Usually idiopathic, may be a/w persistent fetal vasculature

38
Q

DDx of severe APD (2-3+)

A

Optic nerve disease (ischemic optic neuropathy, optic neuritis, tumor, glaucoma), CRAO, CRVO, less commonly a lesion of the optic chiasm or tract

39
Q

DDx of mild APD (1+)

A

any causes of more severe APD, amblyopia, dense vit heme, advanced AMD, BRVO, BRAO, RD, other retinal disease

40
Q

DDx of ocular motility limitation without exophthalmos and resistance to retropulsion

A

Isolated CN 3, 4, or 6 palsy, multiple ocular motor nerve palsies (eg. cavernous sinus and assoc. syndromes), myasthenia gravis, CPEO and assoc. syndromes, orbital blow-out fx with muscle entrapment, ophthalmoplegic migraine, Duane syndrome, other CNS disorders

41
Q

DDx of Optic disc atrophy

A

MC: Glaucoma, prior CRVO or CRAO, prior Ischemic optic neuropathy, chronic optic neuritis, chronic papilledema, compression of optic nerve/chiasm/tract, prior traumatic optic neuropathy

LC: syphilis, retinal degeneration (eg. RP), toxic or metabolic optic neuropathy, LHON, Leber congenital amaurosis, radiation neuropathy, lysosomal storage disease (Tay-sachs), other congenital/hereditary optic atrophy

42
Q

DDx of Paradoxical pupillary reaction (pupil dilates in light and constricts in darkness)

A

Congenital stationary night blindness, congenital achromatopsia, optic nerve hypoplasia, Leber congenital amaurosis, Best disease, optic neuritis, dominant optic atrophy, albinism, RP, rarely amblyopia

43
Q

DDx of EOM thickening on imaging

A

MC: thyroid orbitopathy (often spares tendon), idiopathic orbital inflammatory syndrome

LC: Tumor (eg. lymphoma, mets, or spread of lacrimal gland tumor), c-c fistula, superior ophthalmic vein thrombosis, cavernous hemangioma, rhabdomyosarcoma (peds)

44
Q

DDx of Optic nerve lesion (Isolated)

A

MC: Optic nerve glioma (esp in kids), optic nerve meningioma (esp in adults)

LC: Mets, Leukemia, idiopathic orbital inflammatory syndrome, sarcoidosis, increased intracranial pressure w/ secondary ON swelling

45
Q

DDx of Nystagmus in infancy

A

Congenital nystagmus, albinism, Leber congenital amaurosis, CNS (thalamic injury), spasmus nutans, optic nerve or chiasmial glioma, optic nerve hypoplasia, congenital cataracts, aniridia, congenital corneal opacities

46
Q

Postop complications:

DDx of Shallow AC w/ increased IOP

A

Pupillary block glaucoma, capsular block syndrome, suprachoroidal hemorrhage, malignant glaucoma

47
Q

Postop complications:

DDx of Shallow AC w/ decreased IOP

A

Wound leak, choroidal detachment, overfiltration after glaucoma filtering procedure

48
Q

DDx of Hypotony

A

Wound leak, choroidal detachment, cyclodialysis cleft, retinal detachment, ciliary body shutdown, pharm aqueous suppression, overfiltration after glaucoma filtering procedure

49
Q

DDx of progressive hyperopia

A

orbital tumor pressing on posterior surface of the eye, serous elevation of the retina (eg. CSCR), posterior scleritis, presbyopia, hypoglycemia, cataracts, after radial keratotomy or other refractive surgery

50
Q

DDx of progressive myopia

A

High (pathologic) myopia, diabetes, staphyloma and elongation of the globe, corneal ectasia (keratoconus or s/p K refractive surgery), medications (eg. miotic drops, sulfa drugs, tetracycline), childhoold (physiologic)

51
Q

DDx of Altitudinal field defect

A

MC: Ischemic Optic Neuropathy, HRAO/BRAO, HRVO/BRVO, optic neuritis

LC: Glaucoma, optic nerve or chiasmal lesion, optic nerve coloboma

52
Q

DDx of Arcuate scotoma

A

MC: glaucoma

LC: Ischemic optic neuropathy (esp. nonarteritic), optic disc drusen, high myopia, optic neuritis

53
Q

DDx of Binasal field defect

A

MC: glaucoma, bitemporal retinal disease (eg. Retinitis pigmentosa)

LC: bilateral occipital disease, tumor or aneurysm compressing both optic nerves or chiasm, chiasmatic arachnoiditis, nonphysiologic

54
Q

DDx of bitemporal hemianopsia

A

MC: chiasmal lesion (eg. Pituitary adenoma, meningioma, craniopharyngioma, aneurysm, glioma)

LC: tilted optic discs

Rare: nasal retinitis pigmentosa

55
Q

DDx of Blind spot enlargement

A

Papilledema, glaucoma, optic nerve drusen, optic nerve coloboma, myelinated (medullated) nerve fibers off the disc, drugs, myopic disc with a crescent, MEWDS, Acute idiopathic blind spot enlargement syndrome (AIBSE - may be on spectrum with MEWDS)

56
Q

DDx of Central scotoma

A

Macular disease, optic neuritis, ischemic optic neuropathy (more commonly produces an altitudinal defect), optic atrophy (eg. from tumor compressing the nerve, toxic or metabolic disease)
Rarely: occipital cortex lesion

57
Q

DDx of constriction of peripheral visual fields (tunnel vision)

A

glaucoma, retinitis pigmentosa or other peripheral retinal disorders (eg. gyrate atrophy), chronic papilledema, s/p PRP or cryotherapy, CRAO w/ cilioretinal artery sparing, bilateral occipital lobe infarction w/ macular sparing, nonphysiologic vision loss, medications (eg. phenothiazines), vit. A deficiency, CAR, MAR, or autoimmune-associated retinopathy

58
Q

DDx of homonymous hemianopsia

A

Temporal, parietal, or occipital lobe lesion of the brain (eg. stroke and tumor more common, aneurysm and trauma less common), optic tract or lateral geniculate body lesion. Migraine may cause transient homonymous hemianopsia.

59
Q

DDx of vitreous opacities

A

asteroid hyalosis, vit heme, inflammatory cells from vitritis or posterior uveitis, snowball opacities of pars planitis or sarcoidosis, normal vitreous strands from age-related vitreous degeneration, tumor cells, FB, hyaloid remnants, synchysis scintillans, rarely: amyloidosis or Whipple dz.

Wills Eye Manual (5 decks)

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