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Ophthalmology Review: Physical Exam and Common Eye Conditions

Ophthalmology Physical Exam

  • Pupils

    • Assess size, shape, symmetry; check if equal, round, reactive to light, and accommodation.

    • Swinging flashlight test to evaluate the relative afferent pupillary defect (RAPD): shine light into one eye and observe both pupils’ responses; failure of the contralateral pupil to constrict suggests RAPD.

    • Near reflex: convergence, pupillary constriction, and lens accommodation.

  • Extraocular movements (EOMs)

    • Perform cardinal fields of gaze to detect strabismus, ambylopia risk, or nystagmus and determine motion/direction abnormalities.

  • External examination

    • Look for erythema, edema, swelling, induration, drainage; inspect lid margin lashes, lacrimal apparatus, conjunctiva, and sclera.

    • Cranial nerve innervation mnemonic for EOMs: LR6 SO4 3 (lateral rectus innervated by CN VI; superior oblique by CN IV; all other EOMs by CN III).

  • Slit lamp and tonometry

    • Slit lamp allows detailed view of anterior chamber, cornea, and retina (not always available in primary care).

    • Tonometry (tenometer) measures intraocular pressure (IOP): normal range ~8-21\text{ mmHg}.

    • Ophthalmoscope used to assess red light reflex, posterior chamber, retina, optic disc, cup-to-macula ratio, and vessels.

Key pathologies and presentations

Orbital cellulitis

  • Emergent infection: involves muscles and fat within the orbit, deeper than the orbital septum.

  • Common sources: sinus or dental infections that spread retro-orbitally; more common in children.

  • Typical pathogens: staphylococcus, streptococcus.

  • Clinical features: ill-appearing child, fever, pain with eye movements, proptosis, periorbital soft tissue swelling, eyelid edema.

  • Distinguishing feature from conjunctivitis/blepharitis: pain with eye movement (ELM-related).

  • Visual changes possible; check RAPD.

  • Diagnosis: CT scan of orbits.

  • Treatment: admit for IV antibiotics (vancomycin + ceftaxime or ceftriaxone); obtain blood cultures prior to antibiotics; surgical intervention often not required.

Dacryocystitis

  • Inflammation/infection of the lacrimal sac (nasolacrimal duct).

  • Common in adults with obstruction; pathogens may include Staphylococcus aureus and other organisms.

  • Signs: indurated, fluctuant lacrimal sac region.

  • Treatment: warm compress; tear-free baby shampoo cleansing; ophthalmic antibiotic ointment; systemic antibiotics if cellulitis is suspected; dilation rarely indicated.

Dacryoadenitis

  • Inflammation of the lacrimal gland; unilateral or bilateral.

  • May be rheumatologic/idiopathic or infectious.

  • Signs: purulent discharge suggesting bacterial infection; culture if indicated.

  • Treatment: topical antibiotics; warm compresses if viral/self-limiting.

Entropion and Ectropion

  • Entropion: lower lid turns inward, lashes contact cornea with blink -> corneal abrasion risk; treatment starts with lubrication; botulinum toxin injections may be used; ENT or surgical options if persistent.

  • Ectropion: lid turns outward; can cause dry eye symptoms and nocturnal corneal exposure; management includes lubrication and potential surgery.

Dacryocystitis in infants (nasolacrimal duct obstruction)

  • Three-month-old with nasal/cranial duct swelling; usually no fever.

  • Top differential diagnosis: dacryocystitis; common spontaneously resolving obstruction by 6–12 months; warm compress and gentle massage recommended; balloon dacryoplasty if unresponsive.

Hordeolum (stye) vs Chalazion

  • Hordeolum: painful, tender pustule on eyelid; treat with warm compress; topical antibiotics; avoid squeezing; replace makeup and towels to prevent recurrence.

  • Chalazion: non-tender, hard granuloma; chronic inflammation, not infection; may spontaneously resolve; referral to ophthalmology for incision/curettage if bothersome; may recur.

Blepharitis

  • Inflammation/infection of eyelid margins and meibomian glands; can cause flaking and irritation.

  • Management: eyelid hygiene with baby shampoo wash, warm compresses; topical antibiotics if not responsive; meibomian gland dysfunction linked to dry eye.

Pterygium (wing-shaped vascular overgrowth)

  • Nasal side toward pupil; due to chronic UV exposure.

  • Management: lubricants; surgical excision if vision affected; may recur.

Entropion vs Ectropion review (example case)

  • 80-year-old with lower lid turning inward causing corneal contact; entropion vs eyelid turning outward described for learning.

Conjunctivitis triad (umbrella term for conjunctival inflammation)

  • Allergic conjunctivitis (allergy): bilateral watery eyes; triggered by seasonal allergies or exposure to animals; may have sneezing/runny nose; treatment includes oral antihistamines (e.g., loratadine 10 mg) and ophthalmic antihistamines (ketotifen, etc.); avoid triggers.

  • Viral conjunctivitis: typically unilateral at onset; watery; not purulent or matted shut; can spread to the other eye; self-limiting with time; supportive care including cool compresses and artificial tears; good hygiene advised.

  • Bacterial conjunctivitis: purulent discharge with morning crusting; contagious; treat with topical ophthalmic antibiotic (e.g., Polytrim); contact lens wearers at risk for Pseudomonas; cover both eyes due to contagion.

Dry eye and tear film disorders

  • Keratoconjunctivitis sicca (dry eye disease): common in older individuals; tearing insufficient or rapid tear evaporation.

  • Tear film structure: lipid layer from meibomian glands; aqueous layer from lacrimal gland; mucin/mucous layer from goblet cells.

  • Management: artificial tears every hour or more frequent; if severe, topical cyclosporine or punctal plugs; emphasize lid hygiene and Meibomian gland function.

Scleritis

  • Very painful, deep red eye with photophobia; pain more intense and deeper than conjunctivitis.

  • Vision may be affected; can threaten globe integrity; urgent ophthalmology referral.

  • Often associated with autoimmune disease (e.g., RA, lupus) and immunosuppression.

Uveitis (inflammation of the uveal tract)

  • Anterior uveitis (iritis): painful red eye with ciliary flush (conjunctival injection around the iris); photophobia; decreased vision; may have constricted pupil and anterior chamber flare; possible hypopyon; urgent ophthalmology referral.

  • Posterior uveitis: can be painless; vision loss; associated with systemic diseases (e.g., sarcoidosis, MS).

Corneal foreign body

  • Foreign body lodged under lid or on cornea; tearing, injection, and a possible rust ring if metallic.

  • Management: remove if visible; irrigate; stain eye with fluorescein if not visible; local anesthesia as needed; sterile removal tools; refer to ENT for larger/central/perforating injuries; update tetanus; prescribe ophthalmic antibiotic.

Corneal foreign body with stain and abrasion

  • After removal, assess for corneal abrasion: pain, redness, photophobia; history of trauma.

  • Treatment: ophthalmic antibiotic; for contact lens wearers avoid contact lens until healed and use fluoroquinolone (e.g., ciprofloxacin).

  • Analgesia: typically OTC NSAIDs or acetaminophen; refer if large or not improving in ~48 hours due to risk of corneal ulcer.

Corneal ulcer / keratitis (stroma involvement)

  • Severe pain, photophobia, reduced vision; may show a stromal abscess; white cells, hypopyon.

  • Etiology: bacterial, viral, fungal; associated with Pseudomonas if improper treatment.

  • Urgent ophthalmology care; aggressive antibiotic therapy.

Herpetic keratitis

  • Common cause of worldwide blindness; dendritic lesion on staining is characteristic.

  • Management: topical antiviral and systemic antiviral (e.g., acyclovir); may require specialized care to promote healing (e.g., contact lens bandage for extended healing).

Acute case review (differential diagnosis practice)

  • 34-year-old female with recent rheumatoid arthritis presents with painful red eyes, decreased vision, sudden onset; exam shows red eye, ciliary flush, pupillary constriction, and flare.

  • Top differential: anterior uveitis; rationale: deep, boring pain typical of scleritis is more severe; anterior uveitis presents with ciliary flush and photophobia; posterior uveitis tends to be painless with vision loss but no pain.

Cataracts

  • Very common; decision to operate depends on functional visual limitations and patient desire; cataract extraction generally results in high patient satisfaction.

Transient monocular vision loss and retinal vascular events

  • Amaurosis fugax (Greek: dark fleeting): transient painless loss of vision; a type of TIA/stroke; caused by transient retinal arterial ischemia due to a transient retinal artery thrombus; may resolve spontaneously but workup for vascular risk is essential.

  • Central retinal artery occlusion (CRAO): acute unilateral painless vision loss; considered a form of stroke; risk factors include atrial fibrillation and carotid disease; exam may reveal a cherry-red spot on a pale macula due to retinal ischemia; urgent revascularization attempts and ophthalmology referral.

  • Central retinal vein occlusion (CRVO): similar unilateral painless vision loss but develops over hours to days; fundus shows diffuse retinal edema, hemorrhages, and cotton-wool spots; urgent ophthalmology referral.

Retinal detachment

  • Presents with flashes of light, floaters, and a curtain or veil that moves across the visual field.

  • Emergent referral for possible laser therapy, cryotherapy, or pneumatic retinopexy to reattach the retina.

Age-related macular degeneration (AMD)

  • Leading cause of irreversible bilateral blindness in some populations; central vision loss with peripheral vision spared; often painless.

  • Symptoms: metamorphopsia, central scotoma.

  • Risk factors: age, smoking, chronic disease.

  • Assessment: Amsler grid (AMSR grid in notes) to detect central vision distortion.

  • Dry AMD: more common, harder to treat; management includes antioxidants, smoking cessation, magnification; little effective treatment.

  • Wet AMD: neovascularization; treated with intravitreal VEGF inhibitors to slow progression.

Glaucoma

  • Open-angle glaucoma: most common (≈95% of cases); gradual peripheral vision loss; treated with topical prostaglandin analogs; laser therapy; monitoring of optic nerve.

  • Acute angle-closure glaucoma: medical emergency; abrupt IOP rise; severe pain; halos, nausea, vomiting; fixed mid-dilated pupil; cloudy cornea; urgent ophthalmology referral; initial management includes acetazolamide to lower IOP and laser peripheral iridotomy.

Diabetic retinopathy

  • Appearance differs by stage: nonproliferative with hard exudates; proliferative with neovascularization and possible vitreous hemorrhage.

  • Management: strict glucose control; anti-VEGF therapy for neovascularization; panretinal laser photocoagulation.

Hypertensive retinopathy

  • Chronic hypertension signs: copper wiring, silver wiring, AV nicking; management focused on blood pressure control.

  • Acute hypertensive retinopathy (hypertensive emergency): optic disc edema, cotton-wool spots; often requires ICU care and urgent management of blood pressure.

Orbital fractures and globe injuries

  • Orbital blowout fracture: diplopia, EOM entrapment; CT for diagnosis; managed by maxillofacial surgery.

  • Globe rupture: ocular emergency; initial stabilization, avoid pressure on eye, ophthalmology urgent care; head elevation if spinal clearance allows; broad management includes IV antibiotics and CT imaging; do not perform fluorescein staining or pressure patching.

Other acute injuries

  • Hyphema: blood in the anterior chamber; associated with blunt trauma; management includes eye shield, upright/sitting position, urgent ophthalmology evaluation; may require surgical drainage; risk of secondary glaucoma.

Strabismus, amblyopia, and vision development

  • Strabismus: ocular misalignment, common in childhood; potential amblyopia risk if misalignment persists.

  • Diagnosis: corneal light reflex test (alternatively known as Hirschberg test) to assess symmetry; cover-uncover test to identify shifting fixation when occluding the eye.

  • Amblyopia: functional reduction in visual acuity; preventable with early intervention (glasses, occlusion therapy, Botox, or surgery depending on cause).

Papilledema and optic neuropathies

  • Papilledema: due to increased intracranial pressure; headaches, nausea/vomiting, neuro deficits; optic disc swelling with retinal hemorrhages and absent venous pulsation.

  • Requires urgent neuroimaging and workup to identify the cause of raised ICP; vision risk if not addressed.

Optic neuritis

  • Rapid unilateral progressive vision loss, central vision loss, decreased color vision; pain with EOM; RAPD may be present; often in women under 50; can be presenting sign of multiple sclerosis.

  • Management: IV corticosteroids; most patients recover vision in 2–3 weeks.

Quick differential practice question (example)

  • Case: 75-year-old male with acute unilateral painless vision loss; comorbidities include GERD, type 2 diabetes, hypertension, atrial fibrillation; denies trauma.

  • Most likely diagnosis: central retinal artery occlusion (CRAO) due to acute retinal ischemia in the setting of vascular risk factors; differentiate from amaurosis fugax (transient) and CRVO (vein occlusion with slower onset).

  • Summary of key differentiators (quick reference):

    • RAPD with severe pain and ciliary flush suggests anterior uveitis or scleritis; deep boring pain suggests scleritis; ciliary flush favors anterior uveitis.

    • CRAO presents with acute unilateral painless loss and a cherry-red spot; urgent referral for revascularization.

    • CRVO presents with painless, gradual loss and diffuse retinal edema with hemorrhages.

    • Acute angle-closure glaucoma features include sudden eye pain, halos, nausea, vomiting, fixed mid-dilated pupil, and cloudy cornea; urgent IOP-lowering therapy needed.

  • Practical exam tips

    • Always assess pupil size, symmetry, and reaction to light; use RAPD as a quick screening tool.

    • For any red eye with severe pain, photophobia, decreased vision, or traumatic injury, escalate to urgent ophthalmology evaluation.

    • Document IOP when indicated and consider slit-lamp findings when available.

Note: All numeric values and clinical thresholds cited above are drawn from the content provided in the transcript and are intended for study notes. Always refer to updated clinical guidelines in real-world practice.