Ocular

 symptoms:  
• Pain  
• Foreign  body  sensation  
• Decreased  visual  acuity  
• Impaired  visual  field  
• Itching  
• Flashes  of  light/Glare/Photophobia  
• Floaters  
• Double  vision  
• Discharge  
• Systemic  symptoms  
o Headache,vomiting/nausea  
 
Acute  visual  loss:  
• Media  opacity  
o Cornea  ulceration  
o Acute  anterior  uveitis  
o Enopthalmitis  
o Acute  closed  angle  glaucoma  
o Viterous  hemorrhage  
• Retina  disease  
o Retinal  detachment  
o CRVO  
o CRAO  
• Optic  nerve  
o Optic  neuritis  
o Ischemic  optic  neuropathy  
• Visual  pathway  disorders  (CVA)  
 
 
Gradual  visual  loss:  
• Glaucoma  
• ARMD  
• Cataracts  
 
Retinal  disease:  
• Sudden  increase  in  floaters,  associated  with  visual  loss  and  lightning  
flashes  (stimulation  of  retina)  
 
Discharge:  
• Infants:  
o Blocked  nasolacrimal  duct  
o Congenital  cataracts  
o Entropion  of  lower  eyelid  
• Adults  
o Surface  irritation:  
§ FB  
§ Conjuctivitis  
 § Keratitis  
 
Diplopia  
• Monocular  
o Cataract/cornea  opacity  
o Lens  dislocation  
• Binocular  
o EOM  paralysis  
 
Examination  of  external  eye:  
• Eyelids:  (ptosis,  lid  retraction,  ectropion,  entropion,  lagopthalmos)  
o Position  and  appearance    
§ With  regards  to  the  limbus  (lid  retraction  etc.)  
o Eyelash  crusting  
o Edema  
o Discharge  
o Inflammation  
• Conjunctiva  
• Sclera  
• Anterior  chamber  
o Lens  to  see  for  any  defect  
o Request  for  fluorescein  stain  
o Red  reflex    
• Eversion  of  upper  eyelid  
 
 
 
Red  reflex  with  central  opacity  
 
Eyelid  inflammation  
 
Blepharitis:  
• Ulcerative  (secondary  staph  infection)  à  characterized  by  falling  lashes  
and  lid  deformity  
• Squamousàcharacterised  by  dandruffs  and  scales  
• Treatment:  
o Cleaning  of  lid  crust  by  cotton  wool  
o Topical  antibiotic  ointment  
o Warm  compress  
 
Stye:  
• Abscess  eyelash  follicle  
• Treatment:  
o Pull  out  hair  follicle  
o Warm  compress  
o Topic  antibiotics  
 
 
 
Chalzion:  
• Blockage  of  duct  of  tarsal  gland  resulting  in  cyst  (meibomian  cyst)  
formation,  which  may  get  infected  
 
Herpes  zoster  opthalmicus:  
• Zoster  activation  in  V1  nerve  (nasocilliary  branch  affected)  à  
Hutchinson’s  sign  à  eye  likely  affected  
o Look  for  cornea  involvement  (herpetic  keratitis)à  topical  
antivirals  and  sterpods  
Ptosis:  
• Causes:  
o Horner’sàsuperior  tarsal  muslce/CN3  palsyàlevator  palpebrae  
o Myasthenia  gravis/other  myopathies  
Lid  retraction:  
• Causes:  
o Overactivity  of  levator  muscle  of  eyelids  due  to  hyperthyroidism  
• Sign:  
o Visible  upper  sclera  between  limbus  and  upper  eyelid  margin  
 
Entropion:  
• Inversion  of  eyelid,  association  with  trichiasis  (inturned  eyelashes)  
• Complications:  
o Chronic  conjunctivitis  
o Cornea  abrasions/ulcerations  
• Causes:  
o Senile  entropion  secondary  to  weakness  of  eyelid  tissue  
o Scar  tissue  from  previous  trauma  
o Late  complication  of  trachoma  
• Treatment:  
o Topical  lubricant  
o Surgical  eversion  of  eyelid  +  removal  of  hair  follicles  
 
Ectopion:  
• Eversion  of  eyelid  
• Complications  
o Watering  due  to  inadequate  drainage  of  lacrimal  secretions  
o Exposure  conjunctivitis  and  keratitis  
• Causes:  
o Scar  tissue  from  previous  trauma  
o Senile  weakness/ectropion  
o Seventh  nerve  palsy  
• Treatment:  
o Surgical  correction  
 
Eyelid  deposits:  
• Benign  
o Xanthelesma,  sebaceous  cyst,  papilomas  
• Malignant:  
 o BCC  
§ Locally  invasive  but  do  not  mets  
§ Complications:  
• Invasion  of  bone  &  brain  
• Loss  of  eye  
§ Treatment:  
• Surgical  excision  
• Radiotherapy  
 
Lacrimal  system:  
• Dacryoadenitisàinflammation  of  lacrimal  gland  
• Dacryocystitisàinflammation  of  the  lacrimal  sac  secondary  to  blockage  of  
the  nasolacrimal  duct  
• Treatment:  
o Dacryocystorrhinostomy  
o Systemic  antibiotics  
o Surgical  drainage  of  pus  
 
Orbit:  
• Preseptal  cellutis  à  inflammation/infection  anterior  to  the  orbital  
septum  
o Causes:  
§ Periorbital  trauma  
§ Dermal  infection  
o Signs:  
§ Lid  edema/erythema/tenderness  
§ NO  proptosis,  chemosis,  EOM  restriction,  decreased  VA,  
RAPD,  no  systemic  signs  
§ NO  pain  on  eye  movement  
o Treatment:  
§ Antibiotics  (Oral  augmentin)  
§ Warm  compress  
§ Topical  Antibiotic  
• Orbital  cellulitisà  inflammation  within  orbital  cavity  
o Causes:  
§ Ethmoidal  sinusitis  
o Signs:  
§ Lid  edema,  erythema,  tenderness  
§ Proptosis,  chemosis,  EOM/opthalmoplegia,  VA  decreased,  
RAPD,  systemic  toxicity  
§ PAIN  on  eye  movement  
o Treatment:  
§ Immediate  referral  
§ IV  antibiotics  
§ CT  scan  
§ Surgical  intervention  
o Complications:  
§ Optic  nerve  compression  
§ Subperiosteal/orbital  abscess  
 Spread  ICN  à  meningitis,  brain  abscess,  cavernous  sinus  
§
thrombosis  
• Exophthalmos  (proptosis  if  <18mm)  
o Anterior  displacement  
o Causes:  
§ Grave’s  disease  
§ Orbital  cellulitis  
§ Retrobulbar  hemorrhage/tumour  
§ Cavernous  sinus  thrombosis  
o Investigation:  
o CT/MRI  orbit  or  U/S  orbits,  TFT  
• Enophthalmos:  
o Posterior  displacement  
o Causes:  
§ Blowout  fractures  
§ Orbital  fat  atrophy  
§ Metastatic  diseases  
 
Bilateral  red  eyes:  
• Bacterial  conjunctivitis  
o Signs:  
§ Mucopurulent  discharge  
§ Sticky  eyelids  
§ Sensation  of  grittiness/FB/burning  
§ Conjunctival  hyperaemia  
§ Lid/conjunctiva  edema  
o Treatment:  
§ Topical  antibiotics  
§ Swabs  and  culture  for  sensitivity  if  not  improving  
o Chlamydia:  
§ Unilateral  (newborns)  
§ Complication:  Keratitis  
§ Investigation:  conjunctival  scraping  à  IF  stain/PCR  
o Gonococccal:  
§ Unilateral,  purulent  (newborns)  
§ Complication:  keratitis,  cornea  perforation  
§ Investigation:  Swab  à  GS+culture  on  choc  agar+Thayer  
martin  
• Viral  conjunctivitis  
o Signs:  
§ Conjunctival  hyperaemia  ++  
§ Palpebrae  follicles  
§ Inflammatory  pseudomembranes  
§ Preauricular/submandibular  lymphadenopathy  
§ Anterior  chamber  examination  à  subepithelial  infiltrates  
§ Keratitis  
o Treatment:  
§ Conservative  
§ Advice  for  infectious  control  
 § Topical  steroids  if  keratitis  
• Allergic  conjunctivitis  
o Acute  allergic  conjunctivitis  
§ Signs:  
• Watery  discharge  
• Lid  edema/erythema  
• Conjunctival  chemosis  (edema  
• No  papillae  à  No  cornea  involvement    
o Vernal  keratoconjuctivitis  
§ Signs:    
• Giant  papillae    
• Limbitis    
• Shield  ulcer  on  cornea  (caused  by  abrasion  from  
papillae)  à  topical  steroids  +  bandage  contact  lens  
§ Treatment:  
• Allergen  avoidance  
• Mast  cell  stabilisers  
• Antihistamine  drugs  (Topical/systemic)  
• Refer  for  steroid  treatment  
 
• Dry  eyes  (keratoconjuctivitis  sicca)  
o Cause:  
§ Decreased  production  
• Sjogren  (AI):  Dry  eye,  dry  mouth  arthritis/CTD/SJS  
• Non-­‐Sjogren:  Age,  gland  scarring,  drugs,  contact  lens  
§ Increased  evaporation  
• Eyelid,  contact  lens,  allergic  conjunctivitis  
o Complications:  
§ Cornea  abrasion/ulceration  
o Treatment:  
§ Medical:  Artificial  tears  
§ Surgical:  punctate  occlusion  (to  preserve  tears),  lid  taping,  
tarsorrhaphy  
 
Unilateral  red  eyes:  
• Acute  closed  angle  glaucoma  
• Acute  iritis,  keratitis,  cornea  ulcer  
• FB  
• Trauma  
 
Keratitis  à  use  fluorescein  stain  to  detect  cornea  epithelial  defects  
Cornea  ulcer:  
• Herpes  simplex  dendritic  ulcer:  
o Reactivation  of  latent  HSV1  which  migrate  down  V1  to  cornea  
o Hutchinson’s  sign  (nasociliary  branch  of  V1)  
o Signs:  
§ Watery,  red,  irritable,  photophobic,  blurring  
 § Decreased  cornea  sensation,  dendritic  ulcer,  geographic  
ulcer  
o Treatment:  topical  acyclovir,  STEROIDS  CONTRAINDICATED  
 
• Bacterial  keratitis  
o Staph,  strep  pyogenes/pneum.  ,  pseudomonas  
o Contact  lens,  trauma,  previous  cornea  disease  
o Signs:    
§ watery,  red,  painful,  decreased  vision,  photophobia  
§ conjunctival  injection,  cornea  ulcer/edema,  hypopyon  
o Investigation:  
§ Cornea  scraping  à  GS  and  culture  (blood  +  choc  
àgonorrhea,  sabourandàfungal)  
o Treatment:  
§ Fortified  broad  spectrum  antibiotics  (gentamycin  +  
cefazolin)  until  sensitivities  known  
 
Cornea  dystrophy:  
• Kerotoconus:  
o Cornea  becomes  conical  in  shape  
o Sign:  
§ High  myopia  and  severe  irregular  astigmatism  
o Treatment:  
§ Hard  contacts  len  
§ Surgical  cornea  graft  
 
Cataract:  
• Opacity  of  clear  lens  
• Cause:  
o Congenital  
o Acquired:  
§ Senile  cataracts  
§ Trauma  
§ UV  light  exposure  
§ DM  
§ Steroids  (posterior  subscapular)  
• Types:  
o Cortical  
o Nuclear  
o Subscapular:   Posterior/Anterior  
• Signs:  
o Blurring  of  vision,  monocular  diplopia,  glare,  
• Complications:  
o Anterior  uveitis  
o Glaucoma    
§ Phacolytic  (protein  leakage  from  lens  deposited  on  
trebecula)  
§ Phacomorphic  (swollen  disc  or  secondary  to  disc  
subluxation)  
 • Investigation:  
o Pre-­‐op  assessment:  
§ BCVA,  slit-­‐lamp,  IOP,  Fundoscopy  
§ General  health  check:  ECG,  BP,  urine  dipstick  
o Pre-­‐op  preparation:  
§ Fast  6  hrs  
§ Pre-­‐op  antibiotics,  mydriatics,  analgesia  
§ Biometry  to  select  IOL  
• Length  of  eyeball  
• Curvature  of  cornea  
• Types:  Multifocal  vs  monofocal,  toric  vs  non-­‐toric  
• Surgery:  
o Intra/extracapsular  
o Phacoemulsification  with  femtosecond  laser  and  foldable  IOL  
• Complications:  
o Posterior  capsule  rupture  à  macular  edema  and  infection  
o Endopthalmitis  
o RD  
o Glaucoma  
o Late:  Posterior  capsule  opacification  à  YAG  laser  capsulotomy  
 
 
 
   
Glaucoma:  
• Optic  neuropathy  with  characteristic  optic  nerve  damage  and  visual  field  
loss  
• Imbalance  between  aqueous  production  and  outflow  of  aqueous    
• Ocular  hypertension:  
o IOP>20mmHg  without  optic  disc  changes  or  visual  field  defect  
• Optic  disc  changes:  
o Increased  C:D  ratio>0.6(normal  <0.4)  or  difference  between  two  
eye  >0.2  
• Types:  
o Primary  open  angle  
o Primary  close  angle  
§ Acute  
• Unilateral  red  eye,  blur  vision,  pain,  headache,  N/V  
• Cornea  edema,  fixed  mid-­‐dilated  pupil,  shallow  
anterior  chamber  
§ Chronic  
o Secondary  glaucoma:  
§ DM  (neovascular  glaucoma)  
§ Cataracts  induced  
§ Steroid  induced  
§ Traumatic  
§ Uveitic  à  posterior  synechiae    
• Signs:  
o Increased  cup:disc  ratio,  raised  IOP,  visual  field  defect  
• Investigation:  
o Tonometry  
o Perimetry:  
§ Humphrey  (dynamic)  
§ Goldman  (static)  
o Fundoscopy  
o UBM  (ultrasound  biomicroscopy)  
o OCT  (optical  coherence  topography  
• Treatment:    
o Open  angle  glaucoma  
§ Medical:  
• Prostaglandin  agonist  (topical)  
• Beta  blocker  (topical)  
• Acetazolamide  (topical/oral)  
§ Surgical:  
• Trebeculopasty  
• Trabeculetomy  with  filtering  bleb/drainage  device  
o Close  angle  glaucoma  
§ Medical  
• Topical  mitotics:  pilocarpine  
• Topical  beta-­‐blocker  
• IV  à  oral  acetazolamide  
• Hypeosmotic  agents  IV  mannitol/oral  glycerin  
 § Surgical:  
• Peripheral  laser  iridotomy  +  prophylactic  other  eye  
 
 
Uveitis  
 
Iridocyclitis:  
• Inflammation  of  iris  and  ciliary  body  
• Signs:  
o Unilateral,  painful  red  eye,  photophobia,  blurred  vision  and  watery  
o Circumcilliary  injection,  anterior  slip  lamp  shows  flare  and  cells  in  
anterior  chamber  +  keratic  ppt  on  posterior  surface  of  cronea  
o Pupils  may  be  irregular  due  to  posterior  synechiae  à  secondary  
glaucoma  
• Etiology:  
o AI  diseases/CTD:  RA,  AS,  JIA  
o Infection:  TB,  syphilis,  viral  infection  
• Treatment:  
o Dilate  pupils  to  prevent  posterior  synechia  (mydriatics:  atropine)  
o Topical  steroids  
 
Retinal  disease:  
 
CRAO  
• Signs:  
o Acute  visual  loss  
o Pale  fundus  with  cherry  red  spot,  attenuated  arterioles  
• Causes:  
o Vessel  wall  occlusion:  atheroma/arteritis  (Giant  cell  arteritis  
dxàraised  ESR  and  temporal  artery  biopsy)  
o Embolisation:  heart  valve  etc  
• Management:  
o Ocular  massage  (dislodge  clot)  
o IV  acetazolamide  (decrease  IOP)  
o Anterior  chamber  paracentesis  
o Treat  underlying  
§ 2D-­‐Echo,  ECG,  carotid@  US  
§ Anti-­‐platelet  therapy  
 
CRVO  
• Types:  
o Ischemic:  severe  visual  loss  (RAPD  +ve)  
o Non-­‐ischemic:  mild  visual  loss  
• Signs  
o Acute  visual  loss  
o Flame  shaped  hemorrhages,  cotton  wool  spots,  dilated  tortous  
veins,  macula  edema  (Blood  and  thunder  appearance)  
• Causes:  
o Pressure  on  vein:  Raised  IOP  
 o Vessel  wall  disease  HTN,  DM,  HL,  vessel  wall  inflammation:  SLE,  
sarcoidosis  
o Hypercoagulability/hyperviscousity:  polycythemia/leukemia,  
protein  CS  def  
• Treatment:  
o Underlying  cause  
o Laser  photocoagulation  
o Intra-­‐vitreal  anti-­‐VEGF  
• Branch  CRVO  
o Signs:  Visual  field  loss/blurring  of  vision,  fan-­‐shaped  retinal  
hemorrhages  which  dilate  from  AV  crossing,  macula  edema  
 
Retinal  detachment:  
• Separation  of  the  retinal  neurosensory  layer  from  RPE.  
• Risk  factors:  
o Age  (retinal  degeneration)  
o High  myopia  
o Previous  cataract  surgery  
o Posterior  vitereous  detachment  
• Types:  
o Rhegmatogenous:  single  tear  à  vitreous  fluid  flow  to  cause  
separation  
o Tractional:  proliferative  diabetic  retinopathy  
o Exudative  
• Signs:  
o Floaters,  flashes  of  light,  visual  field  defect  
o Loss  of  red  reflex  with  areas  of  retina  appearing  grey  
• Complication:  
o Progression  to  total  RD  
o Rubeosis  iridis:  neovascularization  of  the  iris  
o Phthisis  
• Treatment:  
o Find  breaks,  relief  traction  (Scleral  buckle,  viterectomy),  seal  break  
(photocoagulation,  cryotherapy)  
 
Macular  disease  
 
ARMD:  
• Age  related  degeneration  of  bilateral  macular  
• Risk  factors:  
o Age  
o Smoking  
o Gender:  Female  
o CVRF:  HTM,HL,obesity  
o Hereditary    
• Signs:  
o Distorted/loss  of  central  visual  field    
 o Early  à  hard  drusen  (between  Burch’s  membrane  and  RPE)  à  
soft  drusen  à  late  wet  drusen  with  choroidal  
neovascularisation/late  dry  drusen  (geographic  atrophy)  
• Investigation:  
o Amsler  chart  
o Fundal  fluorescein  angiographic  test  à  subretinal  hemorrhage  
(treat  with  intra-­‐vitreal  anti-­‐VEGF),  photodynamic  therapy,  direct  
photocoagulation  
• Treatment:  
o Age-­‐related  eye  disease  study:    
§ Supplements:  
• Zinc,  copper  
• Vit  ACE  
 
Retinitis  Pigmentosa  
• Pan-­‐retinal  dystrophy  characterized  by  peripheral  visual  field  loss  and  
defective  night  blinding  
• Signs:  
o Proliferation  of  retinal  pigment  (dark  brown  black  bone  spicules  
around  blood  vessels)  similar  to  scarred  retinal  from  previous  
photocoagulation  
• Associated  with  deafness,  cataract,  glaucoma  
 
 
Viterous  hemorrhage:  
• Sudden  loss  of  visual  loss  due  to  tear  of  blood  vessels  from  trauma,  retinal  
tear  or  from  abnormal  blood  vessels  bleeding  from  ARMD  (wet  drusens)  
or  proliferative  diabetic  retinopathy.  
• Treatment:  
o Conservative  à  blood  absorb  over  many  months  
o Surgery  à  viterectomy  
 
 
Diabetic  retinopathy:  
• Types:  
o Non-­‐proliferative  
§ Mild:  microaneurysms,    
§ Moderate:  hard  exudates,  dot  hemorrhage,  blot  
hemorrhages,  flame-­‐shape  hemorrhagecotton  wool  spots  
§ Severe:    
• 4  quadrants  blot  hemorrhage  
• 2  quadrants  venous  beading  
• 1  quadrant  intra-­‐retinal  microvascular  
abnormalities  
o Proliferative  
§ With  neovascularization  
§ Visual  loss  due  to  vitreous  hemorrhage  or  tractional  retinal  
detachment  
o With  or  without  maculopathy    
 Hard  exudates  and  macula  edema  (dark  cystic  area  of  
§
macula)  
§ Clinical  significant  macula  edema:  
Retinal  thickening  within  500  µm  of  the  macular  
center.  Hard  exudates  within  500  µm  of  the  macular  
center  with  adjacent  retinal  thickening.  One  or  more  
disc  diameters  of  retinal  thickening,  part  of  which  is  
within  one  disc  diameter  of  the  macular  center  
• Treatment:  
o Optimise  glycemic  control  and  other  systemic  RF  
o Laser  photocoagulation  (Pan-­‐retinal  photocoagulation/Macula  
laser  for  macula  edema)  
o Viterectomy  à  vitreous  hemorrhage    
o Anti-­‐VEGF  intravitreal  
 
Hypertensive  retinopathy:  
• Asymptomatic,  bilateral,  symmetrical,  small  vessel  (arterioles)  disease  
• Pathophysiology:  
o Arteriolar  narrowing  (vasoconstriction/atherosclerosis)  
o Focal  closure  of  vasculature  à  cotton  wool  spots/hemorrhage  
o Leakage  à  edema  and  exudates  
o Disc  swelling  
• Classification  (Keith  Wagener  Barker  Classification)  
o Stage  0  -­‐>  Stage  4  (Malignant  hypertension)  papiloedema  
§ Stage  1  arteriolar  narrowing  
§ Stage  2  AV  nipping  
§ Stage  3  hemorrhage,  exudate,  silver  lining  
§ Stage  4  disc  swelling  
• Complications:  
o RVO/RAO  
o NAIO