Wills DDx of Ocular signs Flashcards
AC hyphema
V
I: iris neovascularization, herpes simplex/zoster iridocyclitis
T: traumatic
A: fuchs heterochromic iridocyclitis
M: blood dyscrasia or clotting disorder (e.g. hemophilia)
I: iatrogenic (intraocular surgery or laser), anticoagulation,
N: intraocular tumor (e.g. juvenile xanthogranuloma, RB, angioma)
AC hypopyon
V
I: infectious cornea ulcer, endophthalmitis
severe iridocyclitis (e.g. HLA-B27 associated, Behcet disease), severe inflammatory reactions from a recurrent cornea erosion
T
A
M
I: reaction to an intraocular lens (sterile hypopyon), retained lens particle, device contaminant after cataract surgery (TASS), retained intraocular foreign body, drugs (e.g. rifampin)
tight contact lens
chronic cornea edema with ruptured bullae
N: intraocular tumor necrosis (e.g. psuedohypopyon from retinoblastoma)
Blood in Schlemm Canal on Gonioscopy
compression of episcleral vessels by gonioprism (iatrogenic)
Sturge-Weber syndrome
AV fistula [e.g. carotid-cavernous sinus fistula (c-c fistula)]
SVC obstruction
hypotony
Cornea/conjunctival findings conjunctival swelling (chemosis)
allergy any ocular/periocular inflammation post-operative drugs venous congestion (e.g. c-c fistula) angioneurotic edema myxedema
conjunctival dryness (xerosis)
V
I: Sjogren syndrome
post-cicatricial conjunctivitis, chronic dacryoadenitis
T A: S-J syndrome, OCP M: vitamin A deficiency I: exposure (e.g. lagophthalmos, absent blink reflex, proptosis), radiation N
Cornea edema (congenital)
congenital glaucoma
CHED (AR is present at birth, AD form later onset)
PPMD
birth trauma (forceps injury)
Cornea edema (acquired)
V I: HSV or zoster keratitis, iritis T: traumatic, exposure, chemical injuries A M: fuchs endothelial dystrophy iridocorneal endothelial (ICE) syndrome PPMD I: post-operative edema, aphakic or PBK failed corneal graft CL overwear acute increase in intraocular pressure (e.g. angle-closure glaucoma) cornea hydrops (decompensated keratoconus)
N
cornea edema -dilated episcleral vessels (w/o ocular irritation or paiN)
underlying uveal neoplasm
AV fistula (c-c fistula)
polycynthemai vera
leukemia
ophthalmic vein or cavernous sinus thrombosis
extravascular blockage of ophthalmic/orbital venous outflow
Enlarged cornea nerves: most important
MEN2b (medullary carcinoma of the thyroid gland, pheochromocytoma, mucosal neuromas; may have marfanoid habitus)
Enlarged cornea nerves: others
acanthamoeba keratitis chronic keratitis keratoconus neurofibromatosis fuchs endothelial dystrophy refsum syndrome trauma congenital glaucoma failed cornea graft leprosy ichthyosis idiopathic normal variant
Membranous conjunctivitis: difficult removal of membrane with bleeding (membrane = coagulated exudate adherent to conjunctival epithelium)
adenovirus
streptococci pneuomococci
ligneous conjunctivitis
cornyebacterium diptheriae
chemical burn
HSV
ocular vaccinia
pseudomembranous conjunctivitis: easy removal without bleeding
OCP S-J syndrome Superior limbic keratoconjunctivitis gonococci staphylococci chlamydia in newborns others
cornea opacification in infancy
congenital glaucoma birth trauma (forceps injury) CHED or stromal dystrophy (OU) PPMD developmental abnormalitiy of the anterior segment (e.g. Peters anomaly) metabolic abnormalities (bilateral - e.g. mucopolysaccharidoses, mucolipidoses) interstitial keratitis HSV cornea ulcer cornea dermoid sclerocornea
pannus (superficial vascular invasion of the cornea)
ocular rosacea tight CL or CL overwear phylectenule chlamydia (trachoma and inclusion conjunctivitis) superior limbic keratoconjunctivitis HSV/HZV chemical burn OCP aniridia molluscum contagiousm leprosy
Pigmentation/discoloration of the conjunctiva
racial melanosis (perilimbal) nevus primary acquired melanosis melanoma ocular and oculodermal mealnocytosis (congenital, blue-gray, not conjunctival but episcleral) Addison disease pregnancy radiation jaundice resolving SCH mascara conjunctival/subconjunctival foreign body pharmacologic (chlorpromazine, topical epinephrine)
Symblepharon (fusion of the palpebral conjunctiva with the bulbar conjunctiva)
OCP S-J syndrome chemical burn trauma drugs long-standing conjunctival or episcleral inflammation EKC atopic conjunctivitis radiation congenital iatrogenic (post-surgical)
whorl-like opacity in the corneal epithelium (verticillata)
amiodarone chloroquine fabry disease and carrier state phenothaizines indomethacin
bull’s eye macular lesion
AMD stargardt dz or fundus falvimaculatus albinism cone dystrophy chloroquine or hydroxychloroquine retinopathy Spielmeyer - Vogt syndrome (Batten) central areolar choroidal dystrophy
Choroidal folds
orbital or choroidal tumor idiopathic orbital inflammatory syndrome thyroid eye disease posterior scleritis hypotony RD marked hyperopia scleral laceration papilledema post-operative
CNV (gray-green membrane or blood seen deep to the retina) - MC
AMD ocular histoplasmosis syndrome high myopia idiopathic polypoidal choroidal vasculopathy angioid streaks choroidal rupture (trauma)
CNV (gray-green membrane or blood seen deep to the retina) - LC
drusen of the optic nerve head
tumors
retinal scarring s/p laser photocoagulation
idiopathic
Embolus
platelet-fibrin (dull gray and elongated): carotid dz, less common cardiac
Cholesterol (sparkling yellow, usually at an arterial bifurcation): carotid dz
Calcium (dull white, typically around or on the disc): carotid dz
Cardiac myxoma (rare cardiac tumor, common in young pts, particularly in OS; often occludes the ophthalmic or central retinal artery behind the globe and is not seen)
talc/cornstarch (small yellow-white glistening particles in macular arterioles; may produce peripheral retinal NV: IVDA
Lipid or air (CWS not emboli are often seen): 2/2 chest trauma [purtscher retinopathy] and fracture of long bones
Others (tumors, parasites, other FB)
Macular exudates - MC
DM, CVNM (subretinal), HTN
Macular exudates - LC
Macroaneurysm, Coats dz (children), peripheral retinal capillary hemangioma, RVO, papilledema, radiation retinopathy
Normal DFE in the presence of decreased vision
retrobulbar optic neuritis
other optic neuropathy (e.g. Leber hereditary optic neuropathy, tumor, alcohol or tobacco)
cone degeneration
stargardt disease or fundus flavimaculatus
rod monochromatism
amblyopia
nonphysiologic visual loss
Optociliary shunt vessels on the disc
Vascular: prior CRVO
chronic papilledema (e.g. pseudotumor cerebri) chronic open-angle glaucoma
Neoplastic: orbital or intracranial tumor (especially meningioma)
ON glioma
Retinal NVE (posterior pole)
DM, s/p CRVO
Retinal NVE (peripheral)
Vascular: s/p BRVO
Infectious/inflammatory: syphilis, pars planitis, chronic uveitis
Autoimmune: sarcoidosis,
Metabolic: DM
Iatrogenic/Idiopathic/genetic: sickle cell, coats dz, ROP, Others (leukemia, anemia, Eales, FEVR)
Retinal NVE (retina hemorrhages with white centers) - MC
DM, leukemia, septic chroioretinitis (2/2 to bacterial endocarditis)
Retinal NVE (retina hemorrhages with white centers) -LC
pernicious anemia (and rarely other forms of anemia)
sickle-cell dz
scurvy
lupus and other connective tissue disease
Sheathing of retina vessels (periphlebitis) - MC
syphilis
sarcoidosis
pars planitis
sickle cell disease
Sheathing of retina vessels (periphlebitis) - LC
V I: TB, MS; viral retinitis (HIV, herpes); fungal retinitis, bacteremia T A: Behcet's M I N
Acute increase in IOP
V: suprachoroidal hemorrhage, hyphema, c-c fistula, retrobulbar hemorrhage I: inflammatory OAG, T A M I: acute angle-closure glaucoma, glaucomatocycltic crisis (Posner-Schlossman syndrome) malignant glaucoma post-operative N: other orbital dz
Decreased IOP (hypotony)
V: ocular ischemia I: irdiocyclitis T: ruptured globe, cyclodialysis cleft, traumatic ciliary body shut-down. A M: I: phthisis bulbi, retinal/choroidal detachment severe dehydration drugs (e.g. glaucoma medications) post-operative N
Iris heterochromia (involved iris is lighter than normal)
V
I: Fuchs heterochromic iridocyclitis, chronic uveitis
T
A
M: congenital Horner syndrome, Waardenburg syndrome
I
N: metastatic carcinoma
Iris heterochromia (involved iris is darker than normal)
V
I: Fuchs heterochromic iridocyclitis (depends on blue/brown eye)
T: retained IOFB
A
M: hemosiderosis, siderosis, ICE, ocular melanocytosis or oculodermal melanocytosis
I
N: ocular malignant melanoma, diffuse iris nevus, RB, leukemia, lymphoma
Spontaneous hyphema in child Ddx?
JXG Retinoblastoma ROP PFV Coat’s disease Herpes simplex uveitis
Iris lesion - melanotic (brown)
nevus, melanoma, adenoma, or adenocarcinom of the iris pigment epithelium
Iris lesion - amelanotic (white, yellow, orange)
V I: inflammatory nodule or granuloma (sarcoidosis, TB, leprosy, other granulomatous dz), neurofibroma patchy hypermia of syphilis T A M I: foreign body N: amelanotic melanoma, juvenile xanthogranuloma, cyst, leiomyoma, seeding from posterior segment tumor
NVI
V: ocular ischemic syndrome, s/p vein/artery occlusion, other vascular dz I: chronic uveitis T A M: DM I: chronic RD N: intraocular tumor (melanoma, RB)
iridescent lens particles
drugs hypocalcemia myotonic dystrophy hypothyroidism familial idiopathic
Lenticonus anterior (marked convexity of the anterior lens)
Alport syndrome (hereditary nephritis)
Lenticonus posterior (marked convexity of the posterior lens)
usually idiopathic, may be associated with persistent fetal vasculature
APD - severe 2+ to 3+
optic nerve disease (e.g. ischemic optic neuropathy, optic neuritis, tumor, glaucoma)
CRAO or CRVO
less commonly - lesion of optic chiasm/tract
APD - mild 1+
any of the preceding, amblyopia dense vitreous hemorrhage advanced AMD BRVO or BRAO RD or other retinal disease
limitation of ocular motility without exophthalmos and resistance to retropulsion
V: multiple ocular motor nerve palsies (such as cavernous sinus syndrome)
I
T: orbital blow-out fracture with muscle entrapment
A: CPEO and associated syndromes, myasthenia gravis
M: Duane syndrome
I: other CNS disorder, ophthalmoplegic migraine
isolated CN3, 4, 6 palsy
N
optic disc atrophy - MC
V: s/p CRVO/CRAO, prior ischemic optic neuropathy
I: chronic optic neuritis
T: prior traumatic optic neuropathy
A
M
I: chronic optic neuritis/papilledema, glaucoma,
N: compression of optic nerve/chiasm/tract 2/2 tumor/aneurysm
optic disc atrophy - LC
V I: syphilis T A M: retinal degeneration (RP), toxic or metabolic optic neuropathy, Leber hereditary optic atrophy, Leber cogenital amaurosis, lysosomal storage dz (Tay Sachs) other forms of congenital or hereditary optic atrophy (nystagmus almost always present in congenital forms) I: radiation neuropathy N
Paradoxical Pupillary Reaction (Pupil Dilates in Light and Constricts in Darkness)
"BARADOXICAL" Best's Achromatopsia RP Albinism Dominant Optic nerve atrophy ON hypoplasia XI CSNB Amblyopia (rare) Leber's congenital amaurosis
EOM thickening on imaging - MC
Thyroid orbitopathy (often spares tendon) Idiopathic Orbital Inflammatory Syndrome
EOM thickening on imaging - LC
V: c-c fistula, SO vein thrombosis I T A M I N: Tumor (e.g. lymphoma, metastasis, or spread of lacrimal gland tumor to muscle) cavernous hemangioma (usually appears IN the muscle cone without muscle thickening) rhabdomyosarcoma (children)
ON Lesion (isolated) - MC
optic nerve glioma (esp children)
optic nerve meningioma (esp adults)
ON Lesion (isolated) - LC
metastasis leukemia idiopathic orbital inflammatory syndrome sarcoidosis increased ICP with 2ndary optic nerve swelling
Nystagmus in infancy
V I T: CNS (thalmic) injury A M: congenital nystagmus, albinism I: Leber congenital amaurosis, spasmus nutans, ON hypoplasia, congenital cataracts, aniridia, congenital corneal opacities N: ON or chiasmal glioma
Shallow AC - accompanied by increased intraocular pressure
pupillary block glaucoma
suprachoroidal hemorrhage
malignant glaucoma
Shallow AC - accompanied by decreased intraocular pressure
wound leak
choroidal detachment
over filtration s/p glaucoma filtering procedure
Hypotony
wound leak, choroidal detachment, RD, cyclodialysis cleft, ciliary body shutdown, pharmacologic aqueous suppresion
Progressive hyperopia
V
I: posterior scleritis, Serous elevation of the retina (CSR)
T
A
M: hypoglycemia
I: presbyopia, cataracts, s/p RK or other refractive
N: orbital tumor pressing on the posterior surface of the eye
Progressive myopia
V I T A M: DM I: high (pathologic) myopia, cataract, staphyloma and other elongation of the globe, K ectasia, medications (miotics, sulfa drugs, tetracycline),childhood (physiologic) N
Altitudinal Field Defect - MC
ischemic optic neuropathy, hemi or branch retinal artery or vein occlusion, optic neuritis
Altitudinal Field Defect - LC
glaucoma, ON or chiasmal lesion, ON coloboma
Arcuate Scotoma - MC
glaucoma
Arcuate Scotoma - LC
ischemic optic neuropathy (esp nonarteritic), optic disc drusen, high myopia, optic neuritis
binasal field defect - MC
glaucoma, bitemporal retinal disease (e.g. RP)
binasal field defect - rare
bilateral occipital disease, tumor or aneurysm compressing both optic nerves or chiasm
bitemporal hemianopsia - MC
chiasmal lesion (e.g. pituitary adenoma, meningioma, craniopharyngioma, aneurysm, glioma)
bitemporal hemianopsia - LC
tilted optic discs (LC) and rare (nasal RP)
Blind spot enlargement
V
I: MEWDS, acute idiopathic blind spot enlargement syndrome (may be on spectrum with MEWDS)
T
A
M
I: papilledema, glaucoma, optic nerve drusen, ON colobma, myelinated (medullated) nerve fibers off the disc, myopic disc with crescent, drugs
N
Central scotoma
V: ischemic optic neuropathy (more typically produces an altiduinal field defect)
I
T
A
M
I: optic neuritis, macular disease
N: optic atrophy (e.g. tumor compressing the nerve, toxic or metabolic disease), rarely an occipital cortex lesion
constriction of the peripheral fields leaving a small residual central field (tunnel vision)
V: s/p PRP or cryotherapy, CRAO with cilioretinal artery sparing, bilateral occiptal lobe infarcation with macular sparing
I: rarely medications (e.g. phenothiazines), vitamin A deficiency
T
A: autoimmune-associated retinopathy,
M: RP or other peripheral retinal disorders (gyrate atrophy)
I: chronic papilledema, nonphysiologic visual loss, glaucoma
N: carcinoma, melanoma
homonymous hemianopsia
V: temporal, parietal, or occiptal lobe lesion of the brain (MC: stroke and tumor, LC: aneurysm/trauma)
I
T
A
M
I: migraine (transient homonymous hemianopsia)
N: optic tract or lateral geniculate body lesion
Vitreous opacities
V: VH
I: inflammatory cells from vitritis/posterior uveiits, snowball opacities of pars planitis or sarcoidosis
T: FB
A
M: rarely - amyloidosis or Whipple dz
I: asteroid hyalosis, synchysis scintillans, normal vistreous strands from age-related vitreous degeneration, hyaloid remnants
N: tumor cells
