Opthalmic History Flashcards
Possible presenting complaints and exploding symptoms
Key details
- no 1 eye problem
- how many eyes are involved
- timeline of problem
Key opthalmic symptoms
- visual changes - have there been any changes to your vision? central/peripheral/intermittent/persistent? floaters/photopsia? diplopia?
- red eye - localised or generalised?
- eye discharge/watering - watery or sticky
- gritty/dry eyes - do you feel like there’s something in your eye
- itchy eyes - something stuck in eye?
- photophobia - do you prefer to be in a dark room
- pain/swelling/tenderness of eye/around eye
Eye red flags
Severe eye pain
-acute closed angle glaucoma, uveitis, keratitis
Photophobia - trigeminal irritation => corneal issue
-bacterial keratitis, ant uveitis
Sudden, persistent visual disturbance
-ACUTE VASCULAR EVENT of retina, optic nerve (temporal arteritis), brain
Red eye especially with pain and visual loss - inflammation of conjunctival/ciliary vessels
Trauma
-suspicion of penetrating foreign bodies, retinal detachment, globe rupture?
Exploration of visual disturbance
Visual acuity notation
1 or 2 eyes affected?
Start and onset
- sudden
- gradual
Pattern
- continuous
- intermittent
Type of vision
- near, far or both
- double vision (side by side, on top of each other)
Positive visual symptoms
- flashers, floaters?
- glares from car headlights
Visual distortions - do straight lines look wavy
6/6 - normal vision
-at 6m, your patient can see what a person with normal vision can see from 6m
Add - or + (no they got right or wrong within same line)
Possible differentials for transient visual loss
Possible differentials for persistent sudden painless visual loss
Visual field assessment
Transient loss Migraine - 1hr aura, unilateral Amaurosis fugax - profound sudden unilateral loss -vascular disease/vasculitis Papillodema - ICP
Sudden persistent painless loss - Vascular -retinal vein/artery occlusion -temporal arteritis - anterior ischemic optic neuropathy -stroke affecting vision -vitreous hemorrhage -wet AMD - abnormal blood vessels leak and scar macula Non vascular -retinal detachment
Gradual persistent painless loss
- cataracts
- refractive error
- open angle glaucoma
- dry AMD
- tumours compressing eye structures
- VitA deficiency
Painful persistent loss
- closed angle glaucoma
- optic neuritis
- uveitis
- keratitis
- endopthalmitis - inflammation of inner eye cavities
Eye pain
- site
- onset
Site
- under eyelid - foreign body?
- in eyeball - acute glaucoma
- behind eye - optic neuritis
- frontal headache around eye - migraine?
Onset and time course
- sudden/gradual?
- what were you doing when the pain started?
- continuous/intermittent?
- progression?
Character
- dull/sharp?
- worse on movement?
- something in eye/gritty?
Radiation
Exacerbating, relieving factors
- worse - touch, blinking, moving, photophobia
- better - analgesia, cold water, warm compress, dim lights, removing contact lenses
Associated symptoms
- N+V - acute glaucoma
- unilateral headache, photophobia - aura migraine
- visual changes
- red eye
- discharge, watery?
- gritty, dry, itchy?
Severity - moderate/severe => OPTOMETRIST OR A&E
-especially with N+V, persistent visual loss
Investigating eye trauma
-key questions
MOI
-use of power tools, hammers, chisels, safety goggles => foreign body, penetration, globe rupture
=> URGENT OPTHALMOLOGY REFERRAL
Systemic enquiry related to eyes
B symptoms - temporal arteritis
Cardioresp
- chest pain, pleuritic - AI myocarditis/percarditis, pleuritis
- SOB, cough - AI pleuritis
GI
- N+V - ACAG
- diarrhoea, bloody stools - UC (ant uveitis)
GU
- STI symptoms - chlamydia, gonorrhea
- increased urinary frequency, thirst - diabetes
Neuro
- headache - migraine, temporal arteritis, ACAG, ICP
- weakness, tingling, ataxia - MS, stroke, diabetes
MSK
- joint pain, rashes - RA, SA, SLE, psoriasis
- proximal muscle weakness - polymyalgia rheumatica
Past eye history
Past medical, drug history, allergies
Medications often used in eye conditions
Previous episodes of their PC?
Past eye problems, trauma, surgery (postop endopthalmitis?)
Prescription glasses - long or short sighted
Contacts - daily/monthly/extended
-sleeps, showers, swims with contacts?
-contacts cleaning?
Current medical problems - DM, HTN, AI (uveitis, dry eyes), atopy
- any medical problems you are currently managing? => asthma (timolol CC)
- any prescription, OTC, eye drops, inhalers, herbal remedies
- past surgeries, hospital admissions
- allergies and reactions - eye itch?
Medications used in eye conditions
- lubricants
- ABx, AVx, CS
- glaucoma meds - prostaglandins, Bb, Aa2 (-idine), CAinh (-amide), cholinergics (pilocarpine)
- analgesia - NSAIDs, simple
- antihistamine
FHx
SHx
FHx of eye problems - glaucoma, retinal detachment, cataracts
-HTN, DM, rheumatological conditions
General social context in relation to PC
- accommodation - stairs, lifts
- social support, carer input
- what are you unable to due because of your PC - self care, housework, shopping
- carer input
Smoking - amount and duration
Alcohol
-chronic overuse - B12, folate deficiency => gradual visual loss
Recreational drug use
-IVDU => risk factor for acute retinal vascular events, endopthalmitis
Work - impacts of PC on work
- what does their work involve
- occupational hazards - powertools, welding?
How do you get to work? By car?
Driving - important to advise them not to drive and inform DVLA
-significant visual impairment, eye problems
Visual acuity assessment
- far distance
- documentation
Snellen eye chart
- patient 6m away from chart, wearing glasses
- test each eye separately
- check with pinhole => if clearer, due to uncorrected refractive error => get new glasses
Move patient closer
Finger counting => blind registration
Perception of light
No perception of light
Interpretation - what you can see at 6m/normal vision can see what you can from Xm
6/60 - sight impaired
6/12 - driving acuity
6/6 - normal vision
Notate down the distance that they had up to 2 mistakes on
-add -(no of mistakes) OR +(no correct on next row)
Visual acuity assessment
- near distance
- documentation
Ask patient to read a passage
-test each eye separately
N18 - large print
N5 - good vision
Visual acuity assessment
- colour
- documentation
Colour blindness more common in men than women
13/13 - perfect
Visual field assessment
- central vision
- peripheral vision
- blind spot
Central vision -
- Gross - does any part of my face look distorted or missing
- Formal - Amsler chart
- central distortion - wavy lines
- patch with no vision - scotoma
Compare your visual field with patients
- cover the same eye as the patient
- object equidistant between you => periphery to center
Blind spot - move red pin slowly from midline => temporally
Common visual field defects
- where is the lesion
- possible causes
Monocular vision - optic nerve
-optic neuritis, amaurosis fugax, optic atrophy (ICP compression of II)
Bitemporal hemianopia - optic chiasm
- pituitary adenoma
- craniopharyngeoma
- meningioma
- ICP
Homonymous hemianopia - optic tract
-MCA stroke, tumour
Superior homonymous quandrantopia - temporal optic radiations
Inferior homonymous quadrantopia - parietal optic radiations
-MCA stroke, tumour
Homonymous hemianopia AND MACULA SPARING - PCA stroke
Causes of visual movement conditions
Assessment of squint
Vascular -diabetes, HTN, ischemia Compression -neoplasm, aneurysm Trauma Inflammatory -Graves eyes
Congenital squint - eye cover test -when unaffected eye covered => squinty eye mvs centrally Esotropia - medial => lateral Exotropia - lateral => medial Hypertropia - up => down Hypotropia - down => up
