Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT ocular symtomatology Lecture Notes
OCULAR
SYMPTOMATOLOGY
DIMINUTION OF VISION
Characterization of the loss of vision should
include:
1. Duration
2. Progression: steadily worsening, improving or
static
3. Pattern: constant, intermittent, more for
distance or near, episodic or periodic; and
4. Associated symptoms such as pain, redness,
watering, photophobia, photopsia, floaters,
diplopia, presence of a positive or negative
scotoma or peripheral field defect.
CAUSES OF GRADUAL PAINLESS
VISION LOSS
? Refractive error
? Cataract
? ARMD
? Refractive error
? Chronic (primary) open-angle glaucoma
? Diabetic retinopathy
? Drugs, toxins or nutritional deficiency
? Hereditary retinal dystrophies
? Cerebrovascular disease
? Papilledema
? Compression of optic nerve or optic pathway
CAUSES OF GRADUAL PAINFUL
VISION LOSS
? UVEITIS
? OPTIC NEURITIS
? TRAUMA
SUDDEN PAINLESS
DOV
? RETINAL DETACHMENT
? VIT HAEMORRAGE
? CRVO
? CRAO
? GAINT CELL ARTERITIS
? NAION
ANOMALIES OF OCULAR
MOTILITY
Disturbances of the extra ocular muscles may
manifest as:
1. Eyestrain OR Asthenopia
2. Binocular Diplopia
ASTHENOPIA
Weakness or fatigue of the eyes commonly following
prolonged close work but may also occur after extended
viewing at a distance such watching TV.
Aching/burning of eyes
?
Heaviness of eyelids
?
Headache
?
`Doubling' of letters
Seen in:
? Insufficiency of convergence
? Phorias or other extraocular muscle imbalances
? Uncorrected refractive error
? Uncorrected refractive correction especially of
astigmatism, or early presbyopia.
BINOCULAR DIPLOPIA
? Subjective impression of two images of the same
object seen by the patient when both eyes are
open, but one image disappears on closing either
eye
? Occurs due to the inability of the two eyes to
move together synchronously such that their
foveas are both directed towards a target.
? Seen in:
? Extra ocular muscle paresis
? Restrictive squint
? Displaced globe
DISORDERS OF OCULAR SURFACE
? Ocular irritation
? Lacrimation
? Photophobia
? Red eye
OCULAR IRRITATION
? Sandy or gritty sensation which is generally
worse in the morning.
? The patient may also complain of tiredness of
the eyes or a burning sensation.
LACRIMATION
? 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.
? Caused by irritation of the ocular surface due to the
presence of a foreign particle, inflammation,
chemical injuries or psychogenic factors.
PHOTOPHOBIA
?
Discomfort caused by an abnormal sensitivity to ambient light
conditions.
?
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.
?
Encountered in patients having abnormalities of the corneal
surface or anterior uveitis.
Mild photophobia 1.Keratoconiunctivitis
2.Posterior uveitis.
3.Some drugs and poisons
which dilate the pupil .
True photophobia must be distinguished from
'glare' as well as decreased vision in bright light.
GLARE
Excessive awareness of light could be due to
conditions
allow excess light to enter the eye such as aniridia
and ocular albinism,
produce excessive irregular scattering of light in
the eye such as a posterior sub-capsular cataract.
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,
for photophobia because of the occasionally
reported symptom of having to partly close the
eyes in bright light.
RED EYE
Prominent symptom
1.Anterior uveitis, 2.Keratitis, and
3.Acute angle-closure glaucoma.
The distinguishing features between
conjunctivitis, iritis and glaucoma are given in
the following table:
CONJUNCTIVITIS
INFECTIOUS
1.VIRAL
2.BACTERIAL
NON INFECTIOUS:
1ALLREGIC
2.DRY EYE
2.CHEMICAL REACTION
4.FOREIGN BODY
KERATITIS
INFECTIOUS:
1.FUNAGAL
2.VIRAL
3.BACTERIAL
4.PROTOZOAL I.E ACANTHAMOEBA
NON INFECTIOUS:
CORNEAL EROSIONS
2.FOREIGN BODY
UVEITIS
ACUTE ANGLE CLOSURE GLAUCOMA
D/D'S OF THE COMMON CAUSES
OF A RED EYE
VISUAL PHENOMENA
Glare
Floaters
Photopsia
Uniocular diplopia
Metamorphopsia
Coloured Halos
Visual Hallucinations
Scintillating scotoma
Coloured vision
FLOATERS
? Normal y transparent vitreous gel liquefies and
breaks up, leading to the presence of little particles
and fibrous strands floating in the vitreous
CAUSE
cavity,with age.
? Debris casts shadows onto the retina.
? Black dots, rings, strands, 'spiderlike' images that
are more noticeable against a bright background
COMPLAINTS
and 'move' even when the eye is stationary.
FLOATERS
? Some form of vitreous degeneration and liquefaction
and are usual y benign and age related; they are
INDICATES
also common at a younger age in myopes.
? Showers of dots or a sudden increase in their
numbers Indicate the formation of a retinal tear
? Sometimes the onset of new floaters is secondary to
vitreous haemorrhage, often caused by advanced
diabetic retinopathy.
PHOTOPSIA
? Flashes of light or sensation of flickering lights.
COMPLAINTS
? Vitreous shrinkage or liquefaction, which causes a pull
on the vitreoretinal attachments, irritating the retina
CAUSE
and causing it to discharge electrical impulses.
? These impulses are interpreted by the brain as
'flashes'.
? Phenomenon is usually benign and age- related, but
could be an indicator of a developing retinal tear or an
early retinal detachment.
UNIOCULAR DIPLOPIA
? 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.
? Subluxated lens : two images of an object, one through
aphakic area and other through phakic zone.
? Large iridotomies, if not below the upper lid may also cause
shadowing or uniocular diplopia.
UNIOCULAR DIPLOPIA
? Folded- over retinal flap in giant retinal tears is a rare
cause.
? One image is seen by the macula and projected straight
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
? Patient perceives objects to have an altered,
irregular contour or shape.
? Reviewed for any changes using an Amsler
grid,which tests central 10 degree of vision.
? Central serous choroidopathy,ARMD,diabetic
Seen in macular edema,macular hole
? Micropsia when ordinary, everyday objects
Variant look smaller than normalseen in central serous
chorioretinopathy due to separation of retinal
elements by collection of SRF.
COLOURED HALOS
? Rainbow coloured rings around lights at night.
? Acute angle closure glaucoma,cataract,corneal
Seen in edema,mucus on surface of the conjunctiva.
? Occurs due to prismatic dispersion of light bought
about these conditions.
COLOURED HALOS
? Occurs due to accumulation of fluid in the corneal epithelium &
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.
? A stenopaeic slit is passed before the eye across the line of
vision. glaucomatous halo remains intact but diminished in
intensity whereas,a lenticular halo is broken up into segments
which revolve as the slit is moved.
VISUAL HALLUCINATIONS
? Objects,shapes or lights seen by patients which are not
visible to other persons in the vicinity & are fairly
Definition
specific for disorders involving the cerebral cortex.
? 1.Unformed visual hallucination
Types ? 2.Formed visual hallucination
? Unformed hallucinations consist of seeing distorted
lights as in flashes & spots,lines,objects, or shapes & are
symptoms of lesions affecting the occipital cortex eg.
Migraine & AV malformations.
VISUAL HALLUCINATIONS
? Formed hallucinations are reported as seeing animals,
objects, or people & have specific localizing
value,indicating a lesion affecting temporal lobe cortex
eg. In temporal lobe tumors & epilepsy.
? Formed images could represent misinterpretation of
information in brain due to disruption of areas needed to
process the information.
? Eg. In Charles Bonnet Syndrome, people having a gross
diminution of vision `see' detailed images.
Visual hallucinations can also be due to
transitory or chronic abnormalities in the brain,
caused by changes like:
1. Electrolyte disturbances
2. High fevers
3. Liver or kidney failure
4. Drugs such as diazepam,alprazolam,LSD
SCOTOMATA
A scotoma is an area of partial alteration in the
field of vision consisting of a partially
diminished or entirely degenerated visual acuity
that is surrounded by a field of normal or
relatively well-preserved vision.
Types:
1. Relative scotoma
2. Absolute scotoma
Relative scotoma:
A scotoma in which the visual impairment is not
complete.
Absolute scotoma:
Absolute scotoma an area within the visual field
in which perception of light is entirely lost.
SCINTILLATING SCOTOMATA
In migraine scintillating scotoma of various kinds
occur.
In typical migraine :
Before the attack patient feels unusually well.
Positive scotoma occurs in the field of vision and
while obscuring sight it has a peculiar shimmering
character.
It gradually increases in size until one half of the
field is clouded and fixation point remains
relatively clear.
In dark field, bright spots and fortification spectra
(teichopsia) i.e. rays of various colors is seen
frequently arranged in zigzags.
Homonymous hemianopia usually occurs ( both half
fields are affected )
In other cases :
Whole field becomes clouded but still fixation point is
seen momentarily and then becomes obscured until
the eyes are moved to fresh spot.
Vision usually clears in quarter of an hour.
Attack is soon followed by violent headache.
Intensified on the side of the head opposite the
hemianopic field (hemicrania).
Accompanied by nausea and even sickness (
bilious attack).
During the attack numbness in the mouth and
tongue, slight aphasia are frequent and
copious secretion of urine of low specific
gravity.
Attack occurs periodically but vary in number
and severity.
In mild attack and in advanced age the scotoma
may occur without the headache or the headache
without scotoma.
Migraine is attributed to vasomotor changes in
the brain.
Vasodilatation, associated with a feeling of well-
being, is followed by vasoconstriction,
especially in occipital lobes.
People who suffer ordinary migraine, have
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.
Slight ptosis, diplopia and sluggishness of the
pupillary reactions continue for some hours and
then gradually disappear.
The paresis is worst and persists longer with
succeeding attacks, and eventually sometimes
becomes permanent.
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.
COLOURED VISION
? Also known as Chromatopsia , is a rare
symptom.
? Erythropsia (red vision ) occur in some patients
after cataract extraction if the eyes are exposed
to bright light.
? Objects look red but visual acuity is not
affected and no permanent damage results.
COLOURED VISION
? Patient should be warned of the possibility
of erythropsia as it is somewhat alarming
and suggesting of haemorrhage.
? On the other hand some patients report an
excessive bluish appearance of objects
after cataract extraction because blue light
was filtered out by the yellowish
cataractous nucleus before surgery.
COLOURED VISION
? It is also met with in snow blindness.
? Occur in some cases during the resolution of
optic neuritis when the ensuing atrophy is not
complete.
? In normal people black print will sometimes
suddenly turn deep red owing to strong lateral
light entering the eye through the sclera.
AMBLYOPIA & AMAUROSIS
DEFINITION:
Partial and complete loss of sight, respectively, in one or
both eyes in the absence of ophthalmoscopic or other
marked objective sign.
TYPES OF AMBLYOPIA:
1. Unilateral
2. Bilateral
UNILATERAL AMBLYOPIA
BILATERAL AMBLYOPIA
? Results from physical
? Due to bilateral sensory
suppression of retinal
deprivation as in bilateral
image due to sensory
cataract or corneal
deprivation , i.E.
opacities or bilateral high
Amblyopia or abnormal
refractive error.
binocular interaction.
? Due to anisometropia, with
a unilaterally higher
refractive error
Bilateral visual loss due to various exogenous toxins
with a normal fundus used to be termed as
"Toxic amblyopia".
Now more accurately termed as toxic retinopathies or
neuropathies.
Occurs in uraemia, meningitis and hysteria.
BILATERAL AMAUROSIS
ONSET: Blindness is sudden or rapid (8-24 hrs),
bilateral and complete.
SEEN IN:
1. Acute nephritis especially complicating pregnancy.
2. After scarlet fever.
3. Chronic renal disease.
FUNDUS: No changes unless there is coincident
hypertensive retinopathy.
Vision improves in 10-18 hrs and is fully
restored in about 48 hrs.
In uraemic amaurosis the pupils are dilated but
generally react to light showing that the lower
centres are not affected .
The condition is probably due to circulation of
toxic material, which acts upon the cells of
visual centres.
In cases occuring during pregnancy , there is
usually eclampsia.
AMAUROSIS FUGAX
DEFINITION:
Transient monocular blindness caused by temporary lack
of blood flow either to the brain or retina.
Occurs as a result of emboli from plaques in the carotid
artery.
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
several minutes.
? Sudden loss may appear like a curtain
falling from above or rising from below
and vision may be completely absent at
the height of the attack.
? Recovery occurs in the same pattern.
NIGHT BLINDNESS
Occurs in:
1. Pigmentary retinal dystrophy
2. Xerophthalmia
3. Cirrhosis
Attributed to interference with the functions of
the retinal rods.
COLOUR BLINDNESS &
ACHROMATOPSIA
TYPES:
1. CONGENITAL
2. ACQUIRED
a)PARTIAL- RELATIVE SCOTOMATA
B)COMPLETE- DISEASE OF OPTIC Nerve
In most diseases of retina & choroid, changes in colour
perception affect mostly the blue end of the spectrum.
Slight diminution in acuity of perception of these
rays is caused normal y, owing to their physical
absorption, by the increase of amber pigment in
the nucleus of the lens (blue blindness).
Seen in sclerosing lenses(black cataract).
Congenital colour blindness:
TOTAL
PARTIAL
Rare
Seldom discovered
Nystagmus & central
Subjects compensate scotoma.
for their defect by
attention to shade &
texture
Spectrum appears grey band like the normal scotopic
spectrum, seen with maximum brightness at 510
microns.
Caused by a central
defect.
COLOUR BLINDNESS
Inherited condition- X-linked recessive
Due to absence of one of the photopigments
normally found in the foveal cones.
Red-green cases fall into two chief groups:
1. Protanopes
2. Deuteranopes
Protanopes:
Red end of the spectrum is much less bright than for
normal people.
Shortened spectrum(red end).
Deuteranopes:
Green sensation is defective.
Both have dichromatic vision.
Defects may not be complete & these cases are
called protanomalous & deuteranomalous,
respectively.
NON-ORGANIC
`FUNCTIONAL' VISUAL LOSS
Either due to:
1. Wilful `blind' behaviour (malingering)
2. Subconscious expression of non organic signs
& symptoms of defective vision (hysteria).
MALINGERS
HYSTERIA
Involved with some form of
Little or no insight into their
financial gain in the form of an infirmity & may sometimes
insurance claim, financial
display a complete lack of
compensation, employement
concern over their incapacitating
benefits, an excuse to avoid
symptoms ( la belle indifference)
examinations.
? Most common presentation:
1. Decreased visual acuity in one or both eyes.
2. Constricted visual fields
CONDITIONS WHICH PRODUCE VISUAL LOSS
WITH A NORMAL FUNDUS
This post was last modified on 07 April 2022