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Ophthalmology A Short Textbook_Lang_2000

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	Unilateral or bilateral exophthal-		Thyroid diagnostic studies by
	mos may be present.		endocrinologist are indicated.
	Characteristic eyelid signs (see
	Table 15.3).

	Patient suddenly experiences	Late strabismus with normal	Unequivocal diagnosis.
	diplopia vision (often at the age	sensory development.
	of two to six).
	Patient closes one eye to
	suppress diplopia.

	Scarring limits ocular motility.	Pterygium.	Unequivocal diagnosis.
	Diplopia in temporal gaze.
	Pterygium clearly visible with
	the unaided eye.

Monocular	Gray to white pupillary reflex.	Cataract (multiple focal points in a	Slit-lamp examination. Diagnosis is
	Gradual loss of visual acuity.	single lens).	unequivocal where the opacity is
	Increased glare.		visible under retroillumination.

	Alternating diplopia (dislocated	Dislocation or subluxation of the	Unequivocal diagnosis. Equator of
	lens changes its position in the eye	lens.	the lens is visible in the plane of
	and may fall back into place in the		the pupil under retroillumination.
	plane of the pupil when the patient
	bends forward).

	History of trauma (avulsion of	“Double” pupil due to an iris	Unequivocal diagnosis.
	the root of the iris).	defect (avulsion of the root of the
	Congenital or traumatic aniridia.	iris or aniridia).

	Conical or hemispherical protru-	Keratoconus or keratoglobus.	Unequivocal diagnosis. Condition
	sion deformation of the cornea.	Diplopia results from multiple	may be visible with the unaided
		focal points of the deformed cor-	eye or verified by standard keratos-
		nea.	copy or videokeratoscopy.

533 Symptoms Cardinal 19

Cardinal	Possible associated symptoms	Tentative diagnosis (probable	Further diagnostic work-up
symptoms	and findings	underlying clinical picture)

Enophthalmos (eye recedes into orbit)

History of trauma (signs of ocu-	Fracture of the floor of the orbit.	Obtain radiographs.
lar contusion).		In difficult cases, CT is indicated
Diplopia.		for precise localization of the
Eyelid swelling.		fracture.
Limited ocular motility in eleva-
tion and depression.

Triad of ptosis, miosis, enophthal-	Horner’s syndrome.	Neurologic examination.
mos (unilateral findings).

Blind eye.	Ocular atrophy with shrinkage of	Unequivocal diagnosis.
Phthisis (shrinkage of the eye-	the globe.
ball).

Pseudoenophthalmos (severe trauma, surgery, or retinal detachment) and chronic inflammation (uveitis or retinitis).

Loss of orbital fatty tissue in	Senile sunken eye.	Unequivocal diagnosis.
advanced age (eyes recede into
the orbit).
Always bilateral

Exophthalmos

(projecting eye)

Associated hyperthyreosis (in	Graves’ disease.	Ultrasound and/or CT is indi-
60% of all cases).		cated to determine whether
Often in association with		muscles are thickened.
diplopia.		Thyroid diagnostic studies by
Often in association with kerato-		endocrinologist are indicated.
conjunctivitis sicca.

Symptoms Cardinal 19 534

Metamorphopsia.	Retrobulbar tumor (exophthalmos	CT scan.
Retinal impression folds are vis-	due to posterior pressure on the
ible under ophthalmoscopy.	globe).

History of trauma.	Orbital bleeding.	Radiographs to exclude injury of
Eyelid hematoma (black eye).		the bony structures of the orbit.
Eyelid swelling.

Pseudoexophthalmos due to	Severe myopia.	Refraction testing.
long globe.
Occasionally unilateral.
Difference in refraction (ani-
sometropia).
Poor distance vision; good near
vision.

Pain during eye motion.	Ocular myositis.	Ultrasound scan of the muscles.
Diplopia.
Reddening and swelling of the
eyelid and conjunctiva.

Patients are often children.

Orbital cellulitis.

Severe swelling of the eyelid and conjunctiva.

Severe malaise.

Affected eye is often immobile (“cemented” globe).

Risk of blindness (optic nerve atrophy).

Cavernous sinus thrombosis is a life-threatening sequela.

Consult ENT specialist: Orbital cellulitis originates in the paranasal sinuses in 60% of all cases, and in 84% of all cases in children.

Other developmental anomalies	Craniosynostosis.	Unequivocal diagnosis.
may accompany exophthalmos,
which in these cases is usually
bilateral.

535 Symptoms Cardinal 19

Cardinal	Possible associated symptoms	Tentative diagnosis (probable	Further diagnostic work-up
symptoms	and findings	underlying clinical picture)

Hypopyon	Deep eye pain that hardly	Acute endophthalmitis.
	responds to analgesics at all.
	Reddening and swelling of the
	eyelids and conjunctiva.
	Acutely decreased visual acuity.
	Prior intraocular surgery, pene-
	trating injury, or corneal ulcera-
	tion.

Risk of blindness within hours.

Microbiological diagnostic studies.

	Reddening of the conjunctiva.	Serpiginous corneal ulcer.	Rapid progression of the ulcer
	Corneal ulcer.		can threaten the eye.
	Eyelid swelling.		Microbiological diagnostic stud-
	Pain.		Microbiological diagnostic stud-
	Pain.		ies.
			ies.

	No ocular pain.	Sterile hypopyon.	Diagnostic studies for uveitis.
	Iritis or iridocyclitis.		Systemic, immunologic, and
			rheumatologic examinations are
			required.
Headache
Headache	Unilaterally red, hard eye.	Glaucoma attack.	Risk of blindness.
	Pupil fixed and dilated.		Measure intraocular pressure
	Corneal opacification.		Measure intraocular pressure
	Corneal opacification.		immediately.
	Severe pain.		immediately.
	Severe pain.
	Frequent vomiting.

Sudden unilateral loss of visual acuity.

Patients are usually over 60.

Headache pain in temples.

AION: anterior ischemic optic neuropathy due to arthritis.

Giant cell arthritis in temporal arteritis.

Risk of blindness.

Circular or segmental swelling of the optic disk will be visible upon ophthalmoscopy.

Symptoms Cardinal 19 536

Temporal artery tender to palpation.

Pain when chewing, weight loss.

Poor overall health.

Myalgia.

Stiff neck.

Arterial biopsy and histologic examination are indicated.

Determine erythrocyte sedimentation rate and level of C- reactive protein (precipitous drops occur in temporal arteritis).

Poor vision.

Asthenopic symptoms.

Test visual acuity.

Eyeglasses or change of eyeglass prescription needed.

Rapid fatigue (for example when reading).

Burning sensation.

Flashes of light	Often in older patients.	Posterior vitreous detachment.	Essentially harmless age-related
	Flashes of light and shadows		disorder.
	seen when moving the eyes,		Examine fundus to exclude reti-
	even in the dark.		nal defect.
	Floaters.

	Patient sees shadows (a “wall”	Retinal detachment.	Risk of blindness.
	from below or a “curtain” from		Risk of blindness.
	from below or a “curtain” from
	above).		Ophthalmoscopy.

	Often without any other symp-	Retinal tear.	Risk of retinal detachment.
	toms.		Risk of retinal detachment.
	toms.		Ophthalmoscopy.
			Ophthalmoscopy.

	Often encountered in patients with	Retinitis.	Consult internist for diagnosis of
	consumptive systemic disorders		cause.
	such as AIDS.

537 Symptoms Cardinal 19

Cardinal	Possible associated symptoms	Tentative diagnosis (probable	Further diagnostic work-up
symptoms	and findings	underlying clinical picture)

Eyelid swelling

Inflammatory:

Clear vesicles on the eyelids.	Herpes simplex virus infection.	Unequivocal diagnosis.
Eyelid swelling.
Inflammatory ptosis.

Painful pressure point on the	Hordeolum.	Unequivocal diagnosis.
eyelid.

Circumscribed swelling and reddening of the eyelid.

Often severe pulsating pain.

Spot of yellow pus.

Pseudoptosis.

Sting is often visible.	Insect sting.	Unequivocal diagnosis.
Clear swelling.
Unilateral.
Itching.

Red eye.	Conjunctivitis.	Microbiological diagnostic studies.

Often few symptoms.

Sticky eyelids in the morning.

Purulent or watery discharge.

Large, hard swelling and reddenEyelid abscess.	Unequivocal diagnosis.
ing with edema are often pres-
ent.
Pain.
Ptosis.

Symptoms Cardinal 19 538

Severe pain.

Herpes zoster ophthalmicus.

Refer patient to dermatologist.

Bleeding vesicles.

Pattern of lesions follows trigeminal nerve.

Noninflammatory	Painless, circumscribed swelling	Chalazion.	Unequivocal diagnosis.
	of the eyelid.
	No reddening.
	Hard palpable nodules on the
	eyelid.
	Pseudoptosis.

	Occurs in older patients (elderly	Cutis laxa senilis.	Unequivocal diagnosis.
	skin).	Blepharochalasis.
	Limp, drooping eyelid.
	Drooping eyebrows.

	S-shaped upper eyelid.	Eyelid tumor.	Biopsy.
	No reddening.	Lacrimal gland tumor.
	Palpable mass.

	No other ocular symptoms.	Systemic cause (heart, kidney, or	Refer patient to internist.
		thyroid disorder).

	Yellowish mobile prolapsed fat	Orbital fat hernia.	Unequivocal diagnosis.
	under the eyelids.

	Enophthalmos.	Fracture of the floor of the orbit.	Obtain radiographs.
	History of trauma (ocular con-		In difficult cases, CT is indicated
	tusion).		for precise localization of the
	Diplopia may be present.		fracture.

539 Symptoms Cardinal 19

Cardinal	Possible associated symptoms	Tentative diagnosis (probable	Further diagnostic work-up
symptoms	and findings	underlying clinical picture)

Pseudoptosis

Ptosis

Common:

In older patients.	Cutis laxa senilis.	Unequivocal diagnosis.
Limp eyelid skin.	Blepharochalasis.
Drooping eyelids.

History of trauma (signs of ocu-	Fracture of the floor of the orbit.	Obtain radiographs.
lar contusion).		In difficult cases, CT is indicated
Diplopia may be present.		for precise localization of the
Eyelid swelling.		fracture.
Enophthalmos.

Pseudoenophthalmos.	Phthisis (shrinkage of the eyeball).	Unequivocal diagnosis.
Often secondary to severe
trauma, surgery, or chronic
inflammation (uveitis or
retinitis).
Blind eye.

Palpable, immobile swelling.	Eyelid tumors.	Biopsy.

History of trauma or older patient.	Tear in the levator palpebrae.	Unequivocal diagnosis.

Secondary to intraocular surgery.	Elongation of the levator palpe-	Unequivocal diagnosis.
	brae.

Usually bilateral; present at birth.	Congenital ptosis.	Unequivocal diagnosis.

Symptoms Cardinal 19 540

Rare:	Paralysis of one of all extraocular	Chronic progressive external oph-	Refer patient to neurologist.
	muscles.	thalmoplegia.

Pupillary

dysfunction

Miosis:

Eyelid swelling.	Corneal erosion.	Examine cornea.
Pain.	Corneal foreign body.	Fully evert the eyelids where
Foreign-body sensation.	Subtarsal corneal foreign body.	subtarsal foreign body is sus-
Blepharospasm.		pected.
		Apply fluorescein dye to eval-
		uate cornea where corneal ero-
		sion is suspected.

Secondary to application of anti-	For drug side effects.	Unequivocal diagnosis.
glaucoma medications containing
guanethidine.

Triad of ptosis, miosis, and enoph-	Horner’s syndrome.	Refer patient to neurologist.
thalmos.

Severity of ptosis can vary from day	Myasthenia gravis.	Refer patient to neurologist.
to day.

Accompanied by dilated pupil and	Oculomotor nerve palsy.	Refer patient to neurologist.
diplopia.

Secondary to application of pilo-	Drug-induced miosis.	Unequivocal diagnosis.
carpine.

Secondary to use of morphine.	Toxic miosis.	Unequivocal diagnosis.

Accompanied by ptosis and enoph-	Horner’s syndrome.	Refer patient to neurologist.
thalmos.

Accompanied by iritis or irido-	Reactive miosis.	Unequivocal diagnosis.
cyclitis.
Red eye.
Pain.

541 Symptoms Cardinal 19

Cardinal	Possible associated symptoms	Tentative diagnosis (probable	Further diagnostic work-up
symptoms	and findings	underlying clinical picture)

Pupillary

dysfunction

Mydriasis:

Rings around light sources

Red eye

Secondary to administration of	Drug-induced mydriasis.	Unequivocal diagnosis.
atropine or mydriatics.

Ischemic.	Lesion of the optic nerve or optic	Refer patient to neurologist.
Tumor.	tract.
History of trauma.

Pupil does not respond to light.	Following sudden blindness.	Unequivocal diagnosis.

Gradual progressive loss of	Cataract.	Slit-lamp examination. Diagnosis is
visual acuity.		unequivocal where the opacity is
Increased glare.		visible under retroillumination.
Grayish white pupillary reflex.

Corneal edema.	Increased intraocular pressure.	Measure intraocular pressure.

Conjunctival injection.	Conjunctivitis.	Obtain smear for microbiological
Full visual acuity.		examination.

Purulent or watery discharge.

Swelling of the eyelid and conjunctiva.

Sticky eyelids in the morning.

Combined injection.

Scleritis and/or episcleritis.

Unequivocal diagnosis.

Reduced visual acuity.

Intraocular structures obscured.

Pain.

Symptoms Cardinal 19 542

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