Eye Exam Conditions

Hypertensive Retinopathy

PP: superficial hemorrhages
flame-shaped hemorrhages

E: macular star exudates
cotton wool spots

CM: AV nicking (abrupt end to vessels+no narrowing)
AV tapering (abrupt end to vessels+narrowing)
increased arteriolar light reflex→copper+silver wiring

Diabetic Retinopathy

PP: deeper hemorrhages
dot/blot hemorrhages

E: macular edema
cotton wool spots

CM: ischemia→neovascularization (new blood vessel growth)

Papilledema

PP: increased intracranial pressure→optic nerve edema

E: intracranial mass
intracranial hemorrhage
meningitis

CM: swollen optic disc
blurred margins

Drusen

PP: yellowish round spots

E: normal aging
age-related macular degeneration

CM: yellowish round spots
between optic disc+macula

Cataracts

PP: aging→denaturation of lens protein→opacity of the lens

E: age
UV light
trauma
steroids
diabetes
cigarette smoking
family hx

CM: generalized bilateral blurred vision

PE: cloudy lens

TX: surgical removal+implant

Macular Degeneration

PP/E: part of retina deteriorates

dry (atrophic)→gradual breakdown of cells in macula

wet (exudative/neovascular)→new abnormal blood vessels grow under central retina→leaking/bleeding/scarring

RF: age
family hx
cigarette smoking

CM: blurred/decreased central vision
black spot in middle of vision

PE:
dry→drusen in macula

wet: retinal exudates
neovascularization

Primary Open-Angle Glaucoma (POAG)

PP: optic nerve dx→nerve cell/neuron death→gradual loss of peripheral vision

E: leading cause of visual imapirment+blindness in US
3 million adults
50%→unaware

RF: 65+ y/o
black
diabetes
myopia
ocular hypertension (IOP 21+ mmHg)

CM: asx (no pain)
gradual loss of peripheral vision

DX:
american academy of opthalmology:
-baseline examination→40 y/o
-at-risk→earlier
-known FHx→earlier

PE: optic cup enlargement (glaucomatous cupping)

Acute Angle Closure Glaucoma (AACG)

PP/E: iris blocks exit of aqueous humor from anterior chamber→acute/dramatic elevation of intraocular pressure→nerve cell/neuron death

CM: intense ocular pain
blurred vision
halos around lights
±N/V

PE: diffuse conjunctival injection
fixed+dilated pupil
cloudy cornea
optic cup enlargement (glaucomatous cupping)

Conjunctivitis

PP: diffuse dilation of conjunctival vessels+redness
maximal peripherally

E: bacterial
viral
infections
contagion
allergy
irritation

CM: no pain→mild discomfort
no vision affected (discharge→temporary mild blurring)
watery/mucoid/mucopurulent discharge
pupil not affected
clear cornea

Subconjunctival Hemorrhage

PP: outside blood vessels leak blood→homogenous+sharply demarcated red area

E: none
or
trauma
bleeding dx
cough→sudden increase in venous pressure

CM: no pain
vision not affected
no discharge
pupil not affected
clear cornea

P: resolves over 2 weeks

Corneal Injury

PP: injury to cornea→diffuse conjunctival injection

E: abrasions
injuries
viral
bacterial

CM: moderate-severe+superficial pain
decreased vision
watery/purulent discharge
pupil not affected (unless iritis develops)
infection→corneal opacity+epithelial defect

Corneal Ulcer

PP: ulcer in cornea→diffuse conjunctival injection

E: abrasions
injuries
viral
bacterial

CM: moderate-severe+superficial pain
decreased vision
watery/purulent discharge
pupil not affected (unless iritis develops)
infection→corneal opacity+epithelial defect

DX:
focal white opacity+staining: epithelia defect+underlying hazy white infiltrate

Corneal Injury vs Ulcer

corneal injury:
no break in epithelial layer/bowman’s membrane

corneal ulcer:
break in epithelial layer/bowman’s membrane→allows bacterial into stroma

I: trauma
contact lens use→hypoxia

DX:
focal white opacity+staining: epithelia defect+underlying hazy white infiltrate

Acute Iritis

PP: eye infection→diffuse conjunctival injection

E: systemic infection
herpes zoster
tuberculosis
autoimmune diseases

CM: moderate/aching/deep pain
decreased vision+photophobia
no discharge
small+irregular pupil
clear/slightly clouded cornea+injection confined to corneal limbus

TX: refer promptly to specialist

Vision: Acute Angle Closure Glaucoma

pattern of redness: diffuse conjunctival injection

pain: severe
aching
deep
severe photophobia

vision: decreased

ocular discharge: absent

pupil: dilated
fixed

cornea: steamy
cloudy

significance/E: acute increase in intraocular pressure
emergency

Hordeolum/Stye

PP: painful/tender/red infection of eyelid
inner margin of eyelid→obstructed meibomian gland
outer margin of eyelid→obstructed eyelash follicle/tear gland

E: s. aureus

Chalazoin

PP/E: blocked meibomian gland→subacute/nontender+painless nodule

CM: points inside lid rather than on lid margin/outside lid

Entropion

PP/E: lid margin turns inward→lower lashes irritate conjunctiva+lower cornea

E: elderly

CM: lower eyelid rolled in→lower eyelashes invisible/not present
eyelashes grow in normal spot

Trichiasis

PP: eyelashes growth inside of eyelid→irritate conjunctiva+lower cornea

E: Congenital (present at birth)
Acquired (due to trauma, inflammation, or surgery)
Eyelid malformations
Trachoma (an infectious eye disease)

CM: lower eyelid in normal position

Ectropion

PP/E: lower lid margin turns outward→exposes palpebral conjunctiva→affected eye drainage→tearing

E: elderly
older adults

CM: lower eyelid rolled out→red inside showing
teary eyes

Lid Retraction

PP: abnormal elevation of the upper eyelid
or
depression of the lower eyelid

E: fine tremor+moist skin+heart rate 90+ bpm→hyperthyroidism
thyroid eye dx
aging
trauma
surgery

CM: wide-eyed stare
decreased rim of sclera between upper lid+iris
retracted upper/lower eyelids

PE:
lid lag→positive

Exopthalmos

PP: autoreactive T lymphocytes→protrusion of eyeball

E: thyroid eye dx (especially if unilateral protrusion)
trauma
orbital tumor
granulomatous dxs

CM: protruded eyeball
lid retraction
extraocular muscle dysfunction
dry eyes
ocular pain
lacrimation

Ptosis

PP: drooping of the Upper lid

E: congenital
senescence/aging
myasthenia gravis
CN III dmg
sympathetic nerve (supply) dmg (Horner syndrome)
weakened muscle
relaxed tissues
weight of herniated fat

CM: superior eyelid covers more of the iris than the other/extends over pupil

Xanthelasma

PP: slightly raised+yellowish+well circumscribed+cholesterol-filled plaques
along the nasal portions on one/both eyelids

E: hyperlipidemia (50%)
primary biliary cirrhosis

Blepharitis

PP: chronic inflammation of eyelids
at base of hair follicles

E: s. aureus
malasezzia→scaling seborrheic blepharitis

Pterygium

PP: triangular thickening of bulbar conjunctiva
grows slowly across outer surface of cornea

CM: red eye
irritation
interfered/blurry vision

Pinguecula

PP: yellowish triangular nodule in bulbar conjunctiva

E: aging
appear first on nasal to temporal side

Pupil Dilation vs Constriction

constriction: parasympathetic pathways

dilation: sympathetic pathways

Anisicoria

PP: unequal pupils

E:
greater in bright light→large pupil can’t constrict→parasympathetic
-blunt trauma
-open-angle glaucoma
-oculomotor (CN III) paralysis
-tonic pupil

greater in dim light→small pupil can’t dilate→sympathetic
-horner syndrome

Tonic/Adie Pupil

PP: large/dilated pupil+slowed constriction

E: parasympathetic damage

CM: slow accommodation→blurry vision

PE:
light reaction→severely reduced/slowed/absent+slow/tonic near reaction constriction present

Oculomotor Nerve Palsy/Paralysis

PP: large pupil+ptosis+lateral deviation of eye

E: CN III damage of levator palpebrae muscle

CM: lateral deviation of eye down+out
ptosis of upper eyelid

Horner Syndrome

PP: small+unilateral pupil+slowed dilation

E: congenital (heterochromia)
SNS damage
ipsilateral brainstem lesions
neck+chest tumors affecting ipsilateral sympathetic ganglia
orbital trauma
migraines

CM:
horner syndrome triad:
miosis
ptosis
anhydrosis

loss of sweating on forehead

PE: anisicoria 1+ mm difference
ipsilateral ptosis of eyelid

light reaction→reacts normal+near effort
dim light→dilates slowly

heterochromia→congenital

Argyll-Robertson Pupils

PP: small+irregular+bilateral pupils

E: neurosyphilis
diabetes (rare)

CM/PE:
near vision→constriction
far vision→dilation
light reaction→no reaction

Cranial Nerve III Palsy

CN III (occulomotor nerve)

N: superior rectus
inferior rectus
medial rectus
inferior oblique
levator palpebrae (eyelid)
iris sphincter (pupil)

affected eye→down+out

± pupil dilation

± ptosis

Myopia

PP: refractive disorder
focal point of light rays→in front of the retina→can’t see far away

E: nearsightedness
elongated globe

Hyperopia

PP: refractive disorder
focal point of light rays→behind the retina

E: farsightedness
foreshortened globe

Presbyopia

PP: refractive disorder
focal point of light rays→only distant rays focus on retina

E: dysfunctional lens

Astigmatism

PP: refractive disorder
multiple focal points of light rays→only some rays focus on the retina

E: dysfunctional cornea

Visual Field Physiology

Visual Field Defects: Anopia

direct damage to optic nerve→blind eye

Bitemporal Hemianopsia

damage to optic chiasm→outer (temporal) half of vision gone

Homonymous Hemianopsia

damage to optic tract→side of damaged optic tract gone on both eyes

Homonymous Superior Quadrantic Defect

partial damage to optic radiation→”pie in the sky” vision loss

Cranial Nerve IV Palsy

trochlear nerve

N: superior oblique muscle

looking down+in→weak inferior movement of eye

vertical diplopia

Cranial VI Palsy

abducens nerve

N: lateral rectus muscle

restricted temporal gaze→abduction

horizontal diplopia

Simple Anisicoria

PP: pupillary diameter difference of 0.4+mm

E: 20%→healthy→rarely exceeds 1mm

PE: bright+dim light=equal+brisk constriction to light→normal

Visual Impairment+Legal Blindness (General)

visual impairment
better eye→corrected visual acuity of 20/40 or worse

legal blindness
better eye→corrected acuity of 20/200 or worse

affects daily function

• poor quality of life

• loss of independent living

• falls

• cognitive decline

• family stress

• increased risk for premature death

• other medical comorbidities

Health Maintenance: Visual Impairment

american academy of opthamology

all adults→comprenehsive screening medical eye examination

• visual acuity

• visual fields

• fundoscopic examination

• measuring intraocular pressure

Visual Impairment Etiology

cataracts

age-related macular degeneration

diabetic retinopathy

UV Exposure-Related Eye Injuries+Prevention

injuries

• eyelid cancer

• increased risk of cataracts

• solar retinopathy

prevention

• sunscreen
  -face
  -eyelids

• wear eye protection→sunglasses

Red Eye DDx List

conjunctivitis
-bx
-viral
-allergic
-herpetic

subconjunctival hemorrhage

corneal injury/infxn

acute/anterior iritis

acute angle closure glaucoma