The Eyes Flashcards
Ophthalmic history: redness
Associated factors, e.g. watering, discharge- mucopurulent discharge suggests bacterial infection.
Pain- sharp, dull? aching- anterior segment inflammation, acute glaucoma.
Foreign body sensation- epithelial defect, foreign body.
Photophobia.
Blurred vision.
Contact lens wear.
History of trauma.
Ophthalmic history: diplopia
Is it actually double or blurred? Duration/age of onset. Monocular or binocular? Variable or constant? Horizontal, vertical, or mixed? - horizontal = III, VI nerve palsies. - vertical = IV nerve palsy. - variable = myasthenia gravis. - progressive = thyroid eye disease.
Ophthalmic history: visual loss
Unilateral or bilateral?- uniocular = suggestive of ocular or optic nerve pathology; binocular = lesions at or posterior to the optic chiasm.
Extent: severe visual loss can occur with optic neuropathies; unilateral, segmental visual loss = retinal disorders such as retinal detachment and branch retinal vein occlusion.
Speed of onset: sudden suggests ischaemic changes, gradual is more typical of compressive causes, progression over a few hours to days can occur in optic neuritis.
Ophthalmic history: colour vision abnormalities
Often a feature of optic nerve disease.
Congenital red-green colour discrimination deficiency is seen in 5-8%.
Blue-yellow is rarely due to congenital colour deficiency so a causation should be sought.
Ophthalmic history: flashing lights
Photopsia is the perception of light in the absence of a light stimulus.
Monocular or binocular?- monocular is typically due to vitreoretinal pathology, binocular is usually a cortical phenomenon.
Causes:
-Mechanical retinal stimulation (posterior vitreous detachment, tears) or external compression.
-Subretinal pathology (choroidal neovascularisation, uveitis, choroidal tumours).
-Cortical ischaemia.
-Visual hallucinations.
Ophthalmic history: symptoms to ask about
Redness. Diplopia. Visual loss. Colour vision abnormalities. Flashing lights. Glare. Haloes or starbursts. Floaters. Night-driving problems. Increased myopia.
Ophthalmic history: causes of eye pain
Gritty, sharp pain: corneal epithelial defect (abrasion, keratitis).
Ache, photophobia: iritis.
Pain on eye movement: optic neuritis.
Scalp tenderness, jaw claudication: temporal arteritis.
Nausea, vomiting: acute angle closure glaucoma, raised intracranial pressure (papilloedema).
Ophthalmic history: causes of floaters
Weiss ring following posterior vitreous detachment.
Vitreous condensation.
Vitreous haemorrhage.
Liberated pigment cells associated with retinal tears.
Inflammatory cells.
Tumour cells.
Asteroid hyalosis.
Ophthalmic history: systems enquiry
Use this to explore symptoms that may point to a systemic disease with ocular manifestations.
MS: weakness, paraesthesia, bladder dysfunction.
Thyroid eye disease: heat intolerance, weight loss, irritability, anxiety.
Myasthenia gravis: dysphagia, weakness worse at the end of the day.
Embolic disease: atherosclerotic disease, arrhythmias.
Acoustic neuroma: hearing loss, tinnitus, balance problems.
Rheumatological and collagen vascular disease: arthralgia, rashes.
Ophthalmic history: past medical history
Diabetes.
Hypertension.
Atopy (allergic conjunctivitis).
Rheumatological disease (dry eye, corneal melt, scleritis).
Neurological diseases (VII palsy, exposure keratopathy).
Metabolic disease (hypercalcaemia).
Ophthalmic history: past ocular history
Past ophthalmic surgery: intraocular (endothelial dysfunction) or refractive (post-laser-assisted stromal in situ keratomileusis LASIK, dry eye, flap dehiscence).
Does the patient wear glasses?
Does the patient wear contact lenses? type? overnight wear? cleaning regimen? swimming?
Trauma (physical, chemical, radiation).
Infection: herpes simplex keratitis, herpes zoster ophthalmicus.
Ophthalmic history: drug history
Topical steroid (cataract, glaucoma, herpetic geographic ulcer).
Toxicity to preservatives/drop allergy.
Ethambutol, isoniazid, amiodarone, and ciclosporin can cause optic neuropathy.
Recreational drug use- particularly in atypical pupil abnormalities.
Ophthalmic history: family history
FHx of MS common in patients with optic neuritis.
Contact with infection, conjunctivitis.
Inherited corneal dystrophies.
Glaucoma.
Ophthalmic history: family ophthalmic history
Ask about any eye diseases which run in the family, e.g. glaucoma, inherited retinal dystrophies.
Ophthalmic history: social history
Occupation and hobbies: for visual requirements, e.g. sports, driving, reading.
Country of previous residence (sun exposure, poor sanitation).
Lead and carbon monoxide can cause optic nerve dysfunction.
STD? e.g. syphilis, HIV/AIDS.
Ophthalmic history: causes of diplopia
Horizontal: VI nerve palsy.
Vertical: IV nerve palsy.
Mixed: III nerve palsy.
Mechanical: thyroid eye disease, trauma (orbital wall/floor fracture), idiopathic orbital inflammatory disease, tumour.
Myasthenia gravis.
Decompensating phobia.
Monocular: high refractive disparity between eyes (anisometropia, astigmatism), corneal opacities or ectasias, lens subluxation, iris defects (trauma, laser peripheral iridotomies).
Visual acuity: visual axis, applied anatomy
Light passes through the cornea, anterior chamber, pupil, lens, and vitreous chamber before hitting the retina.
The optic nerve begins at the retina (and is the only part of the CNS that can be directly visualised).
The nerve passes through the optic foramen and joins its fellow nerve from the other eye at the optic chiasm just above the pituitary fossa.
Here, the fibres from the nasal half of the retina decussate.
They continue in the optic tract to the lateral vehicular body.
From there, they splay out such that those from the upper retina pass through the parietal lobe and the others through the temporal lobe.
Fibres from the nasal halves of the retinas cross, so the left side of the brain receives init from the right side of vision (left temporal retina and right nasal retina) and vice versa.
Visual acuity: testing visual acuity
Snellen chart.
In good light conditions, stand the patient 6m from a Snellen chart.
Test each eye in turn unaided or with the glasses they normally use for distance vision.
Repeat the test with a pinhole.
Any improvement in vision implies an uncorrected refractive error (rather than ocular pathology).
Record the lowest line that can be read (allow 2 errors per line).
The number associated with the letters indicates the distance from which a person with normal sight would be expected to read.
Record the visual acuity as the distance from the chart followed by the number at the lowest letters read.
If the patient is unable to see the Snellen chart at all, see if they can count fingers (CF), see hand movements (HM), see light (PL)- if the patient is unable to see light then record as NPL.
Causes of visual loss: cornea
Dry eyes. Corneal abrasion. Corneal ulcer. Herpetic keratitis. Corneal oedema (acute angle closure glaucoma). Keratoconus.
Causes of visual loss: anterior chamber
Iritis.
Hyphaema.
Hypopyon.
Causes of visual loss: lens
Cataract.
Causes of visual loss: vitreous chamber
Vitreous haemorrhage.
Vitritis.
Causes of visual loss: retina
Branch/central artery or vein occlusion. Retinal detachment. Macular degeneration. Macular oedema. Hypertensive retinopathy.
Causes of visual loss: optic nerve
Optic neuritis.
Ischaemic optic neuropathy.
Papilloedema.