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
Visual reflexes
Inspection first
-shape, size of pupil
Look in the distance in lowlight
-accommodation, direct, consensual, swinging light
RAPD - optic nerve/retinal issue => VD of both pupils
PERLA?
Fundoscopy
-explanation and prep
Warn patient that you will get close to their face but you will place your hand on their forehead to prevent any collisions.
Will also use eyedrops to dilate pupils => vision will be blurry and you will be more sensitive to light, please don’t drive
Tropicamide drops
Fundoscopy - red reflex, optic disc assessment
Patient to look into the distance
Red reflex through viewfinder at arms length
Loss => something blocking the retina/retinal problem
-cataracts, retinal detachment, vitreous hemorrhage, retinoblastoma (children)
Optic disc
Contour - well defined
-blurred => papillodema, ICP
Colour - orange pink doughnut with pale center
-pale doughnut => atropy from optic neuritis, glaucoma, ischemia
Cup - small pale center, small cup to disc ratio
-large => loss of neural tissue (glaucoma?)
Funsoscopy - retinal assessment
Look at each quadrant (sup/inf, temp/nasal)
Arteriolar narrowing, AV compression - HTN
Neovascularisation - diabetic retinopathy
Dot and blot hemorrhages - DR
Flame hemorrhages - HTN, retinal vein occlusion, trauma
Cotton wool spots - HTN, DR
Fundoscopy - macula assessment
Temporal to optic nerve - highly pigmented patch
Hard exudates - DR, HTN, retinal vein occlusion
Drusen (yellow spots) - dead retinal pigment epithelium (dry AMD)
Cherry red spot - retinal artery occlusion + sudden profound vision loss
External eye examination
Periorbital
-erythema, swelling - Preseptal/orbital cellulitis
Eyelids
- lumps - benign/malignant
- edema
- ptosis - III?
Eyelashes
- lost - malignancy?
- eyelashes pointing towards eye
- redness, inflammation with collarettes - blepharitis
Pupils
-abnormal, size, shape, colour, symmetry
Conjunctiva
-redness - infection, allergy, trauma inflammation
Cornea
- hazy - AACG, ulceration
- fluorescein staining - epithelial damage, HSV dendritic pattern
Discharge
- watery - allergy, viral conjunctivitis, normal reactive prod
- purulent - bacterial conjunctivitis
- sticky, stringy - chlamydial conjunctivitis
- bloody - gonorrheal conjunctivitis
External eye examination
-areas you are assessing and what you’re looking for
Periorbital
-erythema, swelling - Preseptal/orbital cellulitis
Eyelids
- lumps - benign/malignant
- edema
- ptosis - III?
Eyelashes
- lost - malignancy?
- eyelashes pointing towards eye
- redness, inflammation with collarettes - blepharitis
Pupils
-abnormal, size, shape, colour, symmetry
Conjunctiva
-redness - infection, allergy, trauma inflammation
Cornea
- hazy - AACG, ulceration
- fluorescein staining - epithelial damage, HSV dendritic pattern
Discharge
- watery - allergy, viral conjunctivitis, normal reactive prod
- purulent - bacterial conjunctivitis
- sticky, stringy - chlamydial conjunctivitis
- bloody - gonorrheal conjunctivitis
