Download MBBS Ophthalmology PPT ocular symtomatology Lecture Notes

OCULAR

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SYMPTOMATOLOGY

DIMINUTION OF VISION

Characterization of the loss of vision should

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include:

1. Duration
2. Progression: steadily worsening, improving or

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static

3. Pattern: constant, intermittent, more for

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distance or near, episodic or periodic; and

4. Associated symptoms such as pain, redness,

watering, photophobia, photopsia, floaters,

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diplopia, presence of a positive or negative

scotoma or peripheral field defect.

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CAUSES OF GRADUAL PAINLESS

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VISION LOSS

? Refractive error
? Cataract
? ARMD

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? Refractive error
? Chronic (primary) open-angle glaucoma
? Diabetic retinopathy
? Drugs, toxins or nutritional deficiency

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? Hereditary retinal dystrophies
? Cerebrovascular disease

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? Papilledema
? Compression of optic nerve or optic pathway

CAUSES OF GRADUAL PAINFUL

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VISION LOSS

? UVEITIS
? OPTIC NEURITIS
? TRAUMA

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SUDDEN PAINLESS

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DOV

? RETINAL DETACHMENT
? VIT HAEMORRAGE

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? CRVO
? CRAO
? GAINT CELL ARTERITIS
? NAION

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ANOMALIES OF OCULAR

MOTILITY

Disturbances of the extra ocular muscles may

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manifest as:

1. Eyestrain OR Asthenopia
2. Binocular Diplopia

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ASTHENOPIA

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Weakness or fatigue of the eyes commonly following
prolonged close work but may also occur after extended
viewing at a distance such watching TV.

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Aching/burning of eyes
?

Heaviness of eyelids

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?

Headache

?

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`Doubling' of letters

Seen in:
? Insufficiency of convergence

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? Phorias or other extraocular muscle imbalances
? Uncorrected refractive error
? Uncorrected refractive correction especially of

astigmatism, or early presbyopia.

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BINOCULAR DIPLOPIA

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? Subjective impression of two images of the same

object seen by the patient when both eyes are

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open, but one image disappears on closing either

eye

? Occurs due to the inability of the two eyes to

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move together synchronously such that their

foveas are both directed towards a target.

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? Seen in:

? Extra ocular muscle paresis
? Restrictive squint
? Displaced globe

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DISORDERS OF OCULAR SURFACE

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? Ocular irritation
? Lacrimation
? Photophobia
? Red eye

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OCULAR IRRITATION

? Sandy or gritty sensation which is generally

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worse in the morning.

? The patient may also complain of tiredness of

the eyes or a burning sensation.

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LACRIMATION

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? Reflex increase in the production of tears, as opposed

to epiphora, which signifies an overflow of tears due
to an obstruction to the outflow of tears.

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? Caused by irritation of the ocular surface due to the

presence of a foreign particle, inflammation,
chemical injuries or psychogenic factors.

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PHOTOPHOBIA

?

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Discomfort caused by an abnormal sensitivity to ambient light
conditions.

?

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Due to pain induced by pupillary constriction and ciliary spasm
because of inflammations at the anterior segment, or
stimulation of the terminal fibres of the trigeminal nerve in the
cornea.

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?

Encountered in patients having abnormalities of the corneal
surface or anterior uveitis.

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Mild photophobia 1.Keratoconiunctivitis

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2.Posterior uveitis.
3.Some drugs and poisons
which dilate the pupil .

True photophobia must be distinguished from

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'glare' as well as decreased vision in bright light.

GLARE

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Excessive awareness of light could be due to

conditions

allow excess light to enter the eye such as aniridia

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and ocular albinism,

produce excessive irregular scattering of light in

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the eye such as a posterior sub-capsular cataract.

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Decreased vision in bright light, due to

conditions such as posterior subcapsular
cataract, congenital cone dystrophy and other
central macular disorders may also be mistaken,

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for photophobia because of the occasionally
reported symptom of having to partly close the
eyes in bright light.

RED EYE

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Prominent symptom

1.Anterior uveitis, 2.Keratitis, and
3.Acute angle-closure glaucoma.

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The distinguishing features between

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conjunctivitis, iritis and glaucoma are given in

the following table:

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CONJUNCTIVITIS

INFECTIOUS

1.VIRAL

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2.BACTERIAL
NON INFECTIOUS:

1ALLREGIC

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2.DRY EYE

2.CHEMICAL REACTION

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4.FOREIGN BODY

KERATITIS

INFECTIOUS:

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1.FUNAGAL

2.VIRAL

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3.BACTERIAL

4.PROTOZOAL I.E ACANTHAMOEBA
NON INFECTIOUS:

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CORNEAL EROSIONS

2.FOREIGN BODY

UVEITIS

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ACUTE ANGLE CLOSURE GLAUCOMA

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D/D'S OF THE COMMON CAUSES

OF A RED EYE

VISUAL PHENOMENA

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Glare
Floaters
Photopsia
Uniocular diplopia

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Metamorphopsia
Coloured Halos
Visual Hallucinations
Scintillating scotoma
Coloured vision

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FLOATERS

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? Normal y transparent vitreous gel liquefies and

breaks up, leading to the presence of little particles

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and fibrous strands floating in the vitreous

CAUSE

cavity,with age.

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? Debris casts shadows onto the retina.

? Black dots, rings, strands, 'spiderlike' images that

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are more noticeable against a bright background

COMPLAINTS

and 'move' even when the eye is stationary.

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FLOATERS

? Some form of vitreous degeneration and liquefaction

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and are usual y benign and age related; they are

INDICATES

also common at a younger age in myopes.

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? Showers of dots or a sudden increase in their

numbers Indicate the formation of a retinal tear

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? Sometimes the onset of new floaters is secondary to

vitreous haemorrhage, often caused by advanced

diabetic retinopathy.

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PHOTOPSIA

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? Flashes of light or sensation of flickering lights.

COMPLAINTS

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? Vitreous shrinkage or liquefaction, which causes a pull

on the vitreoretinal attachments, irritating the retina

CAUSE

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and causing it to discharge electrical impulses.

? These impulses are interpreted by the brain as

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'flashes'.

? Phenomenon is usually benign and age- related, but

could be an indicator of a developing retinal tear or an

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early retinal detachment.

UNIOCULAR DIPLOPIA

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? Early senile cataract:
? When light is refracted through wedge shaped areas of

hydration in immature senile cataract, patient sees multiple
images of distant objects such as moon.

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? Subluxated lens : two images of an object, one through

aphakic area and other through phakic zone.

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? Large iridotomies, if not below the upper lid may also cause

shadowing or uniocular diplopia.

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UNIOCULAR DIPLOPIA

? Folded- over retinal flap in giant retinal tears is a rare

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cause.

? One image is seen by the macula and projected straight

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ahead. Other image is due to stimulation of the displaced
retina and is projected to the point in the visual field
normally subserved by that region of the retina.

METAMORPHOPSIA

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? Patient perceives objects to have an altered,

irregular contour or shape.

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? Reviewed for any changes using an Amsler

grid,which tests central 10 degree of vision.

? Central serous choroidopathy,ARMD,diabetic

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Seen in macular edema,macular hole

? Micropsia when ordinary, everyday objects

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Variant look smaller than normalseen in central serous

chorioretinopathy due to separation of retinal

elements by collection of SRF.

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COLOURED HALOS

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? Rainbow coloured rings around lights at night.

? Acute angle closure glaucoma,cataract,corneal

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Seen in edema,mucus on surface of the conjunctiva.

? Occurs due to prismatic dispersion of light bought

about these conditions.

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COLOURED HALOS

? Occurs due to accumulation of fluid in the corneal epithelium &

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to alterations in the refractive condition of the corneal lamellae.

? Halos induced by corneal diseases & early cataractous changes

in the lens may be differentiated by the Fincham's test.

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? A stenopaeic slit is passed before the eye across the line of

vision. glaucomatous halo remains intact but diminished in

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intensity whereas,a lenticular halo is broken up into segments

which revolve as the slit is moved.

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VISUAL HALLUCINATIONS

? Objects,shapes or lights seen by patients which are not

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visible to other persons in the vicinity & are fairly

Definition

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specific for disorders involving the cerebral cortex.

? 1.Unformed visual hallucination

Types ? 2.Formed visual hallucination

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? Unformed hallucinations consist of seeing distorted

lights as in flashes & spots,lines,objects, or shapes & are

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symptoms of lesions affecting the occipital cortex eg.

Migraine & AV malformations.

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VISUAL HALLUCINATIONS

? Formed hallucinations are reported as seeing animals,

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objects, or people & have specific localizing

value,indicating a lesion affecting temporal lobe cortex

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eg. In temporal lobe tumors & epilepsy.

? Formed images could represent misinterpretation of

information in brain due to disruption of areas needed to

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process the information.

? Eg. In Charles Bonnet Syndrome, people having a gross

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diminution of vision `see' detailed images.

Visual hallucinations can also be due to

transitory or chronic abnormalities in the brain,

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caused by changes like:

1. Electrolyte disturbances
2. High fevers
3. Liver or kidney failure

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4. Drugs such as diazepam,alprazolam,LSD

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SCOTOMATA

A scotoma is an area of partial alteration in the

field of vision consisting of a partially

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diminished or entirely degenerated visual acuity
that is surrounded by a field of normal or
relatively well-preserved vision.

Types:

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1. Relative scotoma
2. Absolute scotoma

Relative scotoma:
A scotoma in which the visual impairment is not

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complete.

Absolute scotoma:
Absolute scotoma an area within the visual field

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in which perception of light is entirely lost.

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SCINTILLATING SCOTOMATA

In migraine scintillating scotoma of various kinds

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occur.

In typical migraine :

Before the attack patient feels unusually well.

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Positive scotoma occurs in the field of vision and

while obscuring sight it has a peculiar shimmering

character.

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It gradually increases in size until one half of the

field is clouded and fixation point remains

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relatively clear.

In dark field, bright spots and fortification spectra

(teichopsia) i.e. rays of various colors is seen

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frequently arranged in zigzags.

Homonymous hemianopia usually occurs ( both half

fields are affected )

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In other cases :

Whole field becomes clouded but still fixation point is

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seen momentarily and then becomes obscured until
the eyes are moved to fresh spot.

Vision usually clears in quarter of an hour.

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Attack is soon followed by violent headache.
Intensified on the side of the head opposite the

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hemianopic field (hemicrania).

Accompanied by nausea and even sickness (

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bilious attack).

During the attack numbness in the mouth and

tongue, slight aphasia are frequent and

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copious secretion of urine of low specific
gravity.

Attack occurs periodically but vary in number

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and severity.

In mild attack and in advanced age the scotoma

may occur without the headache or the headache

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without scotoma.

Migraine is attributed to vasomotor changes in

the brain.

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Vasodilatation, associated with a feeling of well-

being, is followed by vasoconstriction,
especially in occipital lobes.

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People who suffer ordinary migraine, have

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attacks in which without any scotoma the
headache is followed by partial paralysis of the
third nerve (ophthalmoplegic migraine) on the
same side as the hemicrania.

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Slight ptosis, diplopia and sluggishness of the

pupillary reactions continue for some hours and
then gradually disappear.

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The paresis is worst and persists longer with

succeeding attacks, and eventually sometimes
becomes permanent.

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Probably most of these cases are not migrainous,

but due to some organic nerve lesion such as
pressure on the third nerve by a distended artery.

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COLOURED VISION

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? Also known as Chromatopsia , is a rare

symptom.

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? Erythropsia (red vision ) occur in some patients

after cataract extraction if the eyes are exposed

to bright light.

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? Objects look red but visual acuity is not

affected and no permanent damage results.

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COLOURED VISION

? Patient should be warned of the possibility

of erythropsia as it is somewhat alarming

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and suggesting of haemorrhage.

? On the other hand some patients report an

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excessive bluish appearance of objects

after cataract extraction because blue light

was filtered out by the yellowish

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cataractous nucleus before surgery.

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COLOURED VISION

? It is also met with in snow blindness.

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? Occur in some cases during the resolution of

optic neuritis when the ensuing atrophy is not

complete.

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? In normal people black print will sometimes

suddenly turn deep red owing to strong lateral

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light entering the eye through the sclera.

AMBLYOPIA & AMAUROSIS

DEFINITION:

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Partial and complete loss of sight, respectively, in one or

both eyes in the absence of ophthalmoscopic or other

marked objective sign.

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TYPES OF AMBLYOPIA:
1. Unilateral
2. Bilateral

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UNILATERAL AMBLYOPIA

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BILATERAL AMBLYOPIA

? Results from physical

? Due to bilateral sensory

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suppression of retinal

deprivation as in bilateral

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image due to sensory

cataract or corneal

deprivation , i.E.

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opacities or bilateral high

Amblyopia or abnormal

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refractive error.

binocular interaction.

? Due to anisometropia, with

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a unilaterally higher

refractive error

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Bilateral visual loss due to various exogenous toxins

with a normal fundus used to be termed as
"Toxic amblyopia".

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Now more accurately termed as toxic retinopathies or

neuropathies.

Occurs in uraemia, meningitis and hysteria.

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BILATERAL AMAUROSIS

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ONSET: Blindness is sudden or rapid (8-24 hrs),

bilateral and complete.

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SEEN IN:
1. Acute nephritis especially complicating pregnancy.
2. After scarlet fever.
3. Chronic renal disease.
FUNDUS: No changes unless there is coincident

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hypertensive retinopathy.

Vision improves in 10-18 hrs and is fully

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restored in about 48 hrs.

In uraemic amaurosis the pupils are dilated but

generally react to light showing that the lower

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centres are not affected .

The condition is probably due to circulation of

toxic material, which acts upon the cells of

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visual centres.

In cases occuring during pregnancy , there is

usually eclampsia.

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AMAUROSIS FUGAX

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DEFINITION:
Transient monocular blindness caused by temporary lack

of blood flow either to the brain or retina.

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Occurs as a result of emboli from plaques in the carotid

artery.

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These block an artery for a while and then move on

resulting in a loss of vision for the duration of blockage.

? Onset is acute and the episode lasts for

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several minutes.

? Sudden loss may appear like a curtain

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falling from above or rising from below

and vision may be completely absent at

the height of the attack.

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? Recovery occurs in the same pattern.

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NIGHT BLINDNESS

Occurs in:
1. Pigmentary retinal dystrophy

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2. Xerophthalmia
3. Cirrhosis

Attributed to interference with the functions of

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the retinal rods.

COLOUR BLINDNESS &

ACHROMATOPSIA

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TYPES:

1. CONGENITAL
2. ACQUIRED

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a)PARTIAL- RELATIVE SCOTOMATA

B)COMPLETE- DISEASE OF OPTIC Nerve

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In most diseases of retina & choroid, changes in colour

perception affect mostly the blue end of the spectrum.

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Slight diminution in acuity of perception of these

rays is caused normal y, owing to their physical

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absorption, by the increase of amber pigment in

the nucleus of the lens (blue blindness).

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Seen in sclerosing lenses(black cataract).

Congenital colour blindness:

TOTAL

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PARTIAL

Rare

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Seldom discovered

Nystagmus & central

Subjects compensate scotoma.

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for their defect by

attention to shade &

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texture

Spectrum appears grey band like the normal scotopic

spectrum, seen with maximum brightness at 510

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microns.

Caused by a central

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defect.

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COLOUR BLINDNESS

Inherited condition- X-linked recessive

Due to absence of one of the photopigments

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normally found in the foveal cones.

Red-green cases fall into two chief groups:
1. Protanopes

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2. Deuteranopes

Protanopes:
Red end of the spectrum is much less bright than for

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normal people.

Shortened spectrum(red end).

Deuteranopes:

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Green sensation is defective.

Both have dichromatic vision.
Defects may not be complete & these cases are

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called protanomalous & deuteranomalous,

respectively.

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NON-ORGANIC

`FUNCTIONAL' VISUAL LOSS

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Either due to:
1. Wilful `blind' behaviour (malingering)
2. Subconscious expression of non organic signs

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& symptoms of defective vision (hysteria).

MALINGERS

HYSTERIA

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Involved with some form of

Little or no insight into their

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financial gain in the form of an infirmity & may sometimes

insurance claim, financial

display a complete lack of

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compensation, employement

concern over their incapacitating

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benefits, an excuse to avoid

symptoms ( la belle indifference)

examinations.

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? Most common presentation:

1. Decreased visual acuity in one or both eyes.

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2. Constricted visual fields

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CONDITIONS WHICH PRODUCE VISUAL LOSS

WITH A NORMAL FUNDUS