OPTOMERIC PRACTICE 1 (SAS 1)

Case History

Patient’s own account of information about his visual problem.

This information is useful to the doctor. It fulfills or assists in completing the knowledge of the practitioner with regard to the following major parts

40 years old

Asians usually before

STATEMENT IS TRUE

Presbyopic age for Asians usually is earlier than Caucasians.

45 years old

Caucasians usually

50 years old

Secondary changes occur after (Age?), up to the age of cataract.

Chief Complaint

Main problem of the patient that compel the patient to seek help with the doctor

Subjective Symptoms

These are felt by the patient and expressed to the doctor.

Example: headache, blurring of vision, tearing

Signs or Objective Symptoms

Not felt by the patient but could be seen by the doctor.

Example: dilated pupil, vertical wrinkles on the forehead, myopic crescent

BV: Uncorrected hyperopia, uncorrected astigmatism, or poor facility of accommodation.

Blurred vision that occurs after prolonged close work, for a Px not a presbyopic age, may be due to?

BV: Night myopia or receptor degeneration, such as retinitis pigmentosa (RP).

Blurred vision occurring primarily in reduced illumination (as in night driving), may be due to?

BV: Nuclear or posterior subcapsular lens opacities.

Blurred vision occurring mainly in bright daylight may be due to?

BV: Temporal arteritis or to carotid artery occlusive disease and therefore lead to closure of the central artery of the retina.

Blurred vision involving a transient loss or obscuring vision in older adults could be due to?

BV: Migraine or to multiple sclerosis.

Blurred vision involving a transient loss of vision in young adults could be due to?

Eyestrain (Asthenopia)

Mused to describe any complaint involving a feeling of fatigue, discomfort, or pain localized in or about the eyes or thought to be associated with the use of the eyes.

Bacterial Conjunctivitis

Most prominent symptoms are irritation and redness of the eyes, a mucopurulent discharge. Complaining of eyes sticking together in the morning.

MX - Treatment is by topical application of anti-bacterial agents, depending upon the responsible bacterium.

Hyperopia

Asthenopia in (?) is due to excessive use of accommodation.

MX: Plus (+) lens

Astigmatism

No amount of accommodation can bring the focus on the retina for object point.

However, in hyperopic astigmatism, one or both focal lines are located behind the retina, and accommodation can place the circle of least confusion on or near the retina.

This will improve the visual acuity at the expense of a feeling of eye strain or fatigue.

MX - Cylinder lens

Binocular Vision Anomalies

Often accompanied by symptoms of eyestrain.

The extent of the symptoms or the absence of symptoms will guide the practitioner in the management of the problem.

Divergence Excess

High exophoria at distance with somewhat lower exophoria at near

Suffers eyestrain and occasional diplopia at distance

MX - Over correcting myopia or under correcting hyperopia or base in prism if exo is also present at near.

Convergence Excess

Complaints of headaches and other signs of asthenopia accompanying close work due to high esophoria at near.

MX - Reading glasses or bifocal lenses or PAL

Convergence Insufficiency

High exophoria at near

May complain of fatigue or even diplopia following prolonged close work.

MX - Orthoptic exercise

Divergence Insufficiency

Esophoria at distance with or without esophoria at near

May suffer symptoms of asthenopia, headaches

MX - Full correction of hyperopia, base out prism

Vertical Phoria

Tendency of the eye to deviate vertically (hyper or hypo phoria)

MX - Prescribing vertical prism

Anisometropia

Unequal amount of refractive error (eg. OD -2.00D, OS -1.00D)

Antisometropia

Opposite refractive error, one is hyperope and the other is myope (eg. OD -2.00D, OS +3.00D)

MX - Contact lens

Aniseikonia

A difference in the size and shape of the retinal images for the two eyes.

Caused by magnification differences brought about by corrective lenses

MX - Contact lens

Strabismus

Permanent deviation of the eye

Concomitant strabismus is an adaptation to a preexisting refractive or binocular vision

High degree of errors of refraction (refractive strabismus)

This could be corrected by glasses.

Accommodative Esotropia

Most likely a high degree of hyperopia will cause esotropia, this is referred to as?

Exotropia

Most likely a high degree of myopia will cause?

Presbyopia HA

Frontal / mid orbital increasing in duration & severity as days go by.

Excessive near work results in residual headache lasting thru the evening & in the morning.

Astigmatism HA

Mid orbital sometimes frontal commences earlier in the day than presbyopia HA but resembles it closely.

Vertical Phoria HA

Over brow / tension & pulling effect, maybe unilateral radiating HA

Esophoria (EP) HA

Result in prolonged near vision

Frontal, mid orbital similar to hyperopia HA, associated with toxemia, internal malfunction requiring medical attention.

High Exophoria (XP) HA

Occipital HA but may extend to the frontal region.

Hyperopia HA

Frontal / mid orbital with series of symptoms such as watery secretion, burning sensation

NO HA - Migraine HA

Dilation and congestion of the branches of the external carotid artery & the meningeal arteries. Nausea is due to stimulation of the vagus nerve.

MX - Going to bed or drinking a cup of black coffee., refer to Neuro

NO HA - Hypertension HA

Characterized as being severe, occurring early in the morning.

MX - refer to internist

NO HA - Nasal Sinusitis HA

Pain is often in the frontal region and most pronounced when stooping down

Other symptoms: coughing due to post nasal drip, low-grade fever, loss of sense of smell.

Itching and Burning

May be due to hyperopia, astigmatism or binocular vision problems.

These symptoms occur in conjunction with hyperemia of the lid margin and conjunctiva.

Efforts to compensate for the refractive error may stimulate sensory nerve endings and therefore, be responsible for local increase in blood supply manifested as hyperemia of the conjunctiva and lid margins, responsible for itching and burning and causing the individual to rub the eyes.

Main factor in the etiology of styes may be rubbing of the eye due to refractive error.

MX - correction of the refractive error and binocular vision problem.

Blepharitis

Inflammatory process affecting the lid margins.

In a seborrheic form, numerous small scales or “dandruff”, may be seen clinging to the lid margins.

MX - washing the hair lashes and scales with a shampoo such as Selsun or baby shampoo

Ulcerative Blepharitis

Bacterial infection is present, the most common cause is staphylococcus.

The ulcerative area along the lid margin leads to loss of eyelashes.

The presence of bacterium and its toxins in the lower conjunctival sac during the night may cause symptoms of eyelids sticking together upon arising and may lead to conjunctivitis and superficial keratitis involving the lower portion of the cornea.

Allergic Conjunctivitis

Intense itching is the most prominent symptom.

A mild non-specific form of conjunctivitis, known as atopic or hay fever conjunctivitis, occurs in association with allergic rhinitis.

Symptoms include itching, tearing and redness of the eye along with edema of the bulbar conjunctiva.

Pain or Foreign Body Sensation

Ask if the pain is superficial, foreign body pain or deep-seated pain.

It will usually be embedded in the upper tarsal conjunctiva and can be removed by everting the upper lid and carefully dislodging it with a sterile cotton applicator.

If embedded in the corneal epithelium, it may be dislodged by irrigating solution.

Deep-Seated Ocular Pain

Caused by more severe conditions, including: corneal ulcer, acute iritis, and acute glaucoma.

An important indication of an internal condition is the presence of ciliary injection. ● This is a lilac-colored injection of the deep conjunctival vessels fanning out from the limbus, as opposed to conjunctival injection, which is a bright red injection of superficial anastomosing vessels and is more prominent toward the fomix.

Visual acuity is also an important guide. A corneal ulcer, iritis, and acute glaucoma will usually result in lowered VA, while foreign body and abrasion will not.

Sensitivity to Light

The triad of pain, photophobia and lacrimation is the well known response to stimulation of the ophthalmic division of the fifth cranial nerve.

Epidemic Keratoconjunctivitis

A highly contagious form of viral conjunctivitis, beginning as an acute follicular conjunctivitis with pain, injection, and tearing.

After 7 days, raised epithelial lesions, staining which fluorescein, may be found scattered over the cornea. At this stage, photophobia may be a marked symptom.

Congenital Glaucoma

Extreme sensitivity to light and excessive tearing in the first few months or years of life should cause the practitioner to suspect the presence of (?).

These symptoms may occur prior to a noticeable enlargement in the size of the eye (buphthalmos) and glaucomatous cupping of the optic nerve head.

Stenosis of the Nasolacrimal Duct

If one of the nasolacrimal ducts fails to open in early life, Dacryocystitis (inflammation of the nasolacrimal) may result.

MX - treatment with antimicrobial agents, probing of the nasolacrimal duct is necessary.

Senile Ectropion

In older individuals, loss of tone of orbicularis muscle may allow the lower lid to become everted or turned outward.

When this occurs, the inferior punctum fails to make contact with the marginal tear strip, so the tears overflow.

MX - surgery designed to shorten the tarsal portion of the lower lid is indicated

Aqueous Deficiency - Keratoconjunctivitis Sicca

An absolute or partial deficiency in aqueous tear production

Symptoms: feeling of dryness, sandy gritty feeling, burning sensation, sensitivity to light

Occurs most often in older women although it can occur in men and younger women; if combined with dry mouth and rheumatoid arthritis, it is known as “Sjogren’s syndrome”

Clinical signs: deficient marginal tear strop, excessive debris in the tear film, mucous threads and filaments in the tear film, poor tear production when measured by means of the Schirmer tear test

MX - use of artificial tears

Mucin Deficiency

The presence (?) can be determined by the use of the precorneal film breakup time test (BUTT)

A BUTT of less than about 10 seconds indicates the presence of mucin deficiency.

However, before concluding that a mucin deficiency is present, the “BUTT” should be repeated a number of times, if the breakup occurs repeatedly in the same area an epithelial defect rather than a mucin deficiency may be the cause.

Most common cause is reduced goblet cell population due to Avitaminosis A.

MX - use of artificial tears particularly those (mucomimetics)

Spots before the Eyes

Due to the presence of vitreous floaters occurring as a result of liquefaction of the vitreous or more serious conditions such as Pars planitis or retinal hemorrhages

Vitreous Floaters

When the vitreous has become partially liquified, which tends to occur in myopes and in older people, fine vitreous opacities may cast a shadow on the retina.

These shadows are commonly seen when looking at the sky or at some other unstructured background.

Patients describe them as spots, strings, cobwebs, rings.

They move across the visual field when eye movements are made, tending to move faster than the eyes move.

These floaters are called Muscae Volitantes, latin for Flying Gnats

Pars Planitis

A form of chronic anterior uveitis affecting the Pars Plana of the ciliary body and occurring usually in young adults.

The only symptom is floating spots due to the presence of inflammatory cells in the retrolental space of the anterior vitreous.

Complications: posterior subcapsular cataracts and cystoid macular edema.

Retinal Hemorrhages

Hemorrhages within the retina or into the vitreous may elicit complaints of “red spots”. Conditions in which retinal or vitreous hemorrhages commonly occur include diabetic retinopathy, hypertensive retinopathy, and vitreous blood dyscrasias.

Light Flashes

Streak of light lasting only a fraction of a second may indicate a presence of vitreous detachment.

This may be differentiated from the scintillating scotoma of migraine by careful questioning An additional cause of light flashes is an irritative lesion of the visual cortex.

Curtain in front of the Eye

This complaint is due to retinal detachment.

The presence of a detachment must be verified by peripheral field testing and by indirect ophthalmoscopy. This is an ophthalmic emergency requiring immediate referral

Distortion of Objects - Metamorphopsia

Occasionally the patient will complain that the object appears to be distorted either in terms of size or shape termed as (?).

The patient’s perception of environmental visual clues to size constancy breaks down, and he may be alarmed that the object such as people’s faces appear larger or smaller than they think they should be.

Halos

Presence of rainbow halos around lights is a classic symptom of angle closure glaucoma. These halos are often seen at night.

Double Vision

Complaints are due to binocular vision problems but there are possibilities that also are uncorrected refractive error and monocular diplopia.

DV - Uncorrected Refractive Error

When the 2 images are not completely apart but tend to blend into one another. ●

It is due to uncorrected astigmatism, uncorrected hyperopia not compensated by accommodation, or to presbyopia

DV - Monocular Diplopia

If this is suspected to be the cause of complaint of double vision, the patient should be asked whether or not it occurs when one eye is closed.

The classic cause of monocular diplopia is Keratoconus.

Clinical signs of Keratoconus: thinning and protrusion of the apex of the cornea seen with the slit lamp, very steep (off scale) keratometer reading, and swirling retinoscopic reflex

The protrusion of the cone (Munson’s sign) may also be seen as an indication in the lower lid when the patient looks downward.

DV - Binocular Vision Problem

If double vision occurs only occasionally, the Px may be found to have large heterophorias at both distance and near, with inadequate fusional vergence

Epicanthus

This complaint is often made by a parent regarding a child, typically, the parent complains that the eye turns inward.

One relatively common cause of this complaint regarding a pre-school child is (?), which is a condition in which one or both inner canthal areas are partly covered by a fold of skin.

As long as the practitioner has ascertained that the eye has not turned in, it is only necessary to reassure the parent that the child is not cross-eyed and that the condition will almost certainly go away by about the age of six.

If it is not found that one eye turns inward, the practitioner should complete a strabismus work up on the child.

Often a high hyperopia will be accompanied with esotropia, a so-called “accommodative esotropia”. Correction of the hyperopia typically straightens the eye.

Protruding Eye

A parent may complain that one of the child’s eyes appears to protrude or to be larger than the other.

While it is possible that one eye can actually be larger than the other, this may indicate a congenital or infantile glaucoma in the larger eye or microphthalmia in the smaller eye.

The larger or protruding eye is the exophthalmic eye.

When this occurs, a tumor or other mass affecting the orbit or the optic nerve should be suspected.

Dyslexia

A condition in which a person sees the letters are inverted or moving which makes them very hard to read or not at all.

Psychological or Hysterical Blindness

Usually reveals a child who cannot see the large E, but can play and walk about without a problem.

Blinking, tics, squinting, and facial grimaces are common symptoms which make parents decide to have their child’s eye examined.