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1 Workup 1.1 Ophthalmic History Ref: Lecture Notes – Ophthalmology Ch2, Oxford Handbook of Ophthalmology Ch1, Uptodate

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1 Workup 1.1 Ophthalmic History Ref: Lecture Notes – Ophthalmology Ch2, Oxford Handbook of Ophthalmology Ch1, Uptodate 1 Workup 1.1 Ophthalmic History Ref: Lecture Notes – Ophthalmology Ch2, Oxford Handbook of Ophthalmology Ch1, UpToDate History of present illness (HPI): □ Chief complaint: → Onset: acute (eg. vascular), subacute (eg. optic neuritis), chronic, acute on chronic (eg. acute glaucoma attack → Laterality: Rt (OD), Lt (OS), both (OU) [NOT ‘LE’] → Quality → Severity → Progression: intermittent vs constant, progressive vs stable → Aggravating and relieving factors □ Associating symptoms: ocular and non-ocular symptoms Complaint Considerations D/dx Preceding trauma? Eyelid pathologies Pattern of redness? – diffuse vs focal? Perilimbic involvement/sparing? Conjunctivitis (allergic, bacterial, viral) Any pain/discomfort? Subconjunctival haemorrhage □ FB sensation → corneal ds Episcleritis □ Severe pain → keratitis, scleritis, Scleritis Red eye glaucoma Corneal ulcer, abrasion, FB Any photophobia? (corneal ds, uveitis) Keratitis Any blurred/loss of vision? Uveitis Any discharge? (conjunctivitis) Trauma Any associating systemic inflammatory diseases? – eg. SNRA, Behcet’s Acute angle closure glaucoma *: requires urgent ophthalmic referral Any contact lens wear? (keratitis) Transient vs persistent? – vascular Amaurosis fugax due to migraine, insufficiency vs structural causes ↑ICP, retinal a. insufficiency Unilateral vs bilateral vs VF defects? – Ocular media: acute angle closure ocular vs retrobulbar pathologies glaucoma, keratitis, uveitis, vitreous Central vs periphery? – macular vs haemorrhage Acute other pathologies Retinal: RAO, RVO, retinal visual loss Any pain? Red eye? (glaucoma, keratitis, detachment, acute maculopathy 1 endophthalmitis, uveitis, optic neuritis) ON: optic neuritis, AION , Associating symptoms? papilloedema, orbital cellulitis compression □ N/V → acute glaucoma Neuro: pituitary apoplexy, visual □ Neurologic deficit → stroke pathway lesions 1 AION = anterior ischaemic optic neuropathy, which can be caused by GCA or other vascular ds affecting optic disc supply. - Page 3 of 133 - Pattern of visual loss? Ocular media: corneal opacity, chronic glaucoma, cataract, vitreous □ Gradual blurring/dimming haemorrhage □ Distortion → usu maculopathy Retinal: ARMD, macular or retinal Chronic □ Constricting → glaucoma dystrophy, DM retinopathy, DM visual loss □ Central loss → maculopathy macular edema, epiretinal membrane, macular hole Any pain? – dull eye pain in glaucoma Optic pathway: optic neuropathy, Systemic disease? – DM visual pathway lesions Seldom the sole presenting symptoms Trauma Usually useful in differentiating cause of Eyelid: lumps, blepharitis other ocular symptoms Anterior processes: dry eye, Discomfort only? – blepharitis, dry eye, conjunctivitis, anterior uveitis, conjunctivitis a/w discomfort keratitis, corneal ulcers, scleritis Ocular pain Severe pain? – keratitis, corneal ulcer, Acute/chronic glaucoma uveitis, glaucoma, endopthalmitis, Orbital disease: orbital cellulitis, optic scleritis, myositis of EOM neuritis, EOM myositis, dysthyroid eye Pain on eye movement? – optic neuritis disease Periorbital pain? – GCA, migraine, Others: cluster headache, migraine, orbital cellulitis, headache syndromes giant cell arteritis Preceding trauma? Monocular vs binocular? – does diplopia disappear after closing one eye → ocular vs malalignment causes Central: INO, failure to control a Separation of image? – vertical, longstanding squint horizontal or oblique Neurogenic: CN3, 4, 6 palsies Provoking gaze direction? – worst direction represents field of action of NMJ: MG Diplopia paretic muscle (opposite if dysthyroid) Myogenic: dysthyroid eye disease, Intermittent? (myasthenia gravis) myositis, myopathy Any corrective head position? Orbital: fracture, space-occupying lesions (eg. tumours) Worse at distance vs near? (MR palsy in near, LR palsy in distance) Monocular: maculopathies, media opacities, refractive errors Any pain? (orbital, aneurysmal, intracranial mass, inf’n/inf’n, DM) Other neurological features? Any dysthyroid features? Congenital ptosis, eg. levator Onset? – congenital vs acute vs chronic abnormality Bilateral vs unilateral? Apnoneurotic ptosis2 Varies diurnally? – MG CN III palsy Ptosis Associated headache or diplopia? Horner’s syndrome Hx of ocular surgery, trauma? Myasthenia gravis FHx of ptosis? Myogenic – mitochondrial myopathy, myotonic dystrophy, FSHD 2 In aponeurotic ptosis, there is spontaneous disinsertion or dehiscence of levator aponeurosis (tendon connecting levator to tarsal plate). It is the commonest cause of acquired ptosis in adults - Page 4 of 133 - Past ocular history (POH): □ Hx of eye disease, incl refractory error Significance of eye complaints: □ Hx of ocular surgery Red eye (redness ± pain, photophobia, □ Hx of eye trauma discharge) → usually indicates anterior □ Hx of contact lens wearing ocular pathology Painless loss of vision Past medical history (PMH): → usually posterior pathology □ Vascular diseases, eg. HTN, DM, coronary or Glare → usually indicates cataract cerebrovascular disease Distortion (metamorphosia), central □ Systemic inflammatory diseases, eg. sarcoidosis, scotoma → usually macular pathology CTD, Behcet’s disease Flashes (photopsia) and floaters □ Allergic diseases, eg. allergic rhinitis → usually vitreoretinal pathology Drug Hx □ Current and past medications Medications to be noted in □ Drug allergies ophthalmological patients: Corticosteroids (a/w glaucoma, Social history: cataract) □ Smoking and alcohol when relevant, eg. vascular event, Hydroxychloroquine unexplained optic neuropathy Amiodarone □ ADL Anti-TB drugs, esp isoniazids Neuroleptics and anticonvulsants Family history, eg. retinitis pigmentosa (inherited), Neuroptics glaucoma (FHx is a RF) - Page 5 of 133 - 1.2 Examination of the Eye Ref: Lecture Notes – Ophthalmology Ch2, Oxford Handbook of Ophthalmology Ch1, IB and JC teaching Basic examination of the eye involves: □ External appearance: eyebrows, eyelids, lacrimal apparatus, obvious ocular abnormalities (eg. squint) □ Visual acuity (VA): distance vs near acuity, aided vs unaided, ± pinhole □ Visual field (VF): confrontation or mid-peripheral vision, Goldman perimeter □ Pupils: symmetry, direct and consensual response, accommodation reflex, swinging torch test □ Ocular movement and alignment: EOM test, Hirschberg test, cover and uncover test Additional examination of the eye involves: □ Fluoroscein staining for corneal abrasion and injury □ Slit lamp (biomicroscopy) for anterior segment examination □ Goldmann tonometer for intraocular pressure measurement □ Fundoscopy: disc, retinal vasculature, macula, peripheral retina 1.2.1 Basic Examination of the Eye A. External Appearance Eyebrows: asymmetry, scarring Eyelids: □ Lumps, eg. stye3, chalazion4, xanthelasma □ Swelling, eg. blepharitis □ Abnormalities in position → Ptosis: measure distance between upper and lower lids and excursion of upper lid from extreme downgaze to extreme upgaze → Entropion and ectropion: eyelid turning inward and outward respectively □ Eyelash problems, eg. trichiasis (lashes arise from normal position but are posteriorly directed Lacrimal apparatus: □ Tear film: epiphora (watery eye), dry eye □ Lacrimal swelling: dacryocystitis (lacrimal sac infection) Other obvious ocular abnormalities, eg. squint 3 Stye (external hordeolum) is an acute eyelash follicular abscess. It is associated with pustule at eyelid margin with erythema, swelling and pain. It is classically due to S. aureus and treatment involves warm compression ± oral Abx. 4 Chalazion refers to chronic inflammation due to obstructed Meibomian (sebaceous) gland. It is initially associated with eyelid swelling and erythema (same as stye) but later becomes a painless, rubbery nodular lesion towards the centre of eyelid. Treatment is again warm compression only - Page 6 of 133 - B. Visual Acuity (VA) Types: □ Unaided vs aided: w/o and w/ spectacles respectively □ Best corrected VA (BCVA): tested w/ trial lenses (gold standard, NOT commonly used) □ Near vs distance: test VA at distance (usu 6m) or near (usu ~30cm) → May be different in myopia and prebysopia Setting and principle: □ Ensure proper illumination □ Use appropriate chart at appropriate distance □ Test each eye in turn and occlude the other using palm of your hand5 or occluder VA expressed as d/D: □ d = distance at which pt is reading chart □ D = distance at which pt is expected to be able to read chart Interpretation: □ Normal = 6/6 (20/20) □ <6/9 (20/30) → use pinhole occluder to correct refractory error □ <6/120 (20/400) → try to determine if pt can → Count fingers (CF) → Hand movement (HM) → Light perception (LP) → No perception of light (NLP) Chart used: □ Snellen’s chart: standard target, placed at 6m (10ft) → Each optotype (letter) subtend 5’ arc and lines subtend 1’ arc → Normal vision = 6/6 (20/20); significant = ≥2 line change □ LogMAR charts, eg. ETDRS chart → MAR = min angle of resolution ≈ 1/Snellen’s quotient (eg. 6/60 = 10) → Equal line/letter spacing and # of optotypes on a row → avoids crowding phenomenon6 → Visual angle doubled every 3 lines → linear ↑difficulty cf Snellen’s □ Other variants, eg. Landolt C, illiterate E test Assessment of VA in children □ ‘Hundreds and thousands’ test for very young children □ Cardiff Acuity test for young children 1-3y □ Sheridan-Gardiner test for older children 5 Fingers should NOT be used (can peek through gaps between fingers). 6 Crowding refers to a phenomenon by which neighboring targets interfere
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