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Download MBBS Ophthalmology PPT ocular symtomatology Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT ocular symtomatology Lecture Notes

This post was last modified on 07 April 2022

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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