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Ophthalmology A Short Textbook_Lang_2000

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Black spots before the eyes (floaters)

Eye hard to palpation.

Glaucoma attack.

Pupil fixed and dilated.

Head and eye pain.

Loss of visual acuity.

Nausea, possibly with vomiting.

Risk of blindness.

Measure intraocular pressure immediately.

	Spontaneous (normal history).	Subconjunctival hemorrhage.	Diagnosis is unequivocal where
	Secondary to exercise (such as		confirmed by patient’s history.

lifting heavy objects, pressing, defecation of hard stool) and coughing or sneezing.

Secondary to trauma or surgery.

Due to arteriosclerosis (may be recurrent in older patients).

With impaired coagulation (hemophilia or medication such as coumarin derivates).

Usually no other ocular symp-	Vitreous opacification.	Unequivocal diagnosis.
toms.
Decreased visual acuity only in
severe cases.

Patients are often older.	Posterior vitreous detachment.	Isolated findings are harmless.
Patient perceives veils and cur-		Examine fundus to exclude reti-

tains in the eye, even in the	nal defects.
dark.
Floaters move with the eye.
Flashes of light.

543 Symptoms Cardinal 19

Inflammatory debris in the vitreous Posterior uveitis.	Examine fundus.
body.
body.

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

Decreased visual acuity

Fundus examination is indicated where visual acuity is decreased.

Transient (visual acuity improves with 24 hours, usually within one hour)

Lasts a few seconds.	Amaurosis fugax (such as in ipsi-	No abnormal ocular findings.
Darkening that may include	lateral stenosis in the internal
amaurosis.	carotid artery).

Poor general health.	Circulatory failure.	No abnormal ocular findings.

Visual acuity improves with improvement in general health.

Visual field defects.

Ocular migraine.

Unequivocal diagnosis.

Scintillating scotoma for 10 – 20 minutes.

Vertigo and vomiting.


Transient	Blurred vision.	Hypoglycemia.	Risk of blindness.
	General feeling of fatigue.		Administer glucose. Diagnosis is
			Administer glucose. Diagnosis is
			unequivocal where visual acuity
			returns to normal as the level of
			blood glucose increases.

Persisting longer	Unilateral loss of visual acuity.	AION: anterior ischemic optic	Determine erythrocyte sedi-
than 24 hours, sud-	Headache is possible.	neuropathy.	mentation rate and level of C-
den onset, painless.			reactive protein (precipitous
			drops occur in temporal
			arteritis).

Symptoms Cardinal 19 544

Mobile shadows before the	Vitreous hemorrhage.	Examine fundus. Diagnosis is
eyes.		unequivocal where fundus is
Allow to clear by immobilizing		obscured.
the eyes so that blood will
settle.

Severe loss of visual acuity.	Retinal detachment.	Risk of blindness.
Flashes of light.		Ophthalmoscopy (clearly visible
		Ophthalmoscopy (clearly visible
		retinal detachment).

Pain from posterior swelling and	Retrobulbar optic neuritis.	Neurologic examination.
with eye motion.
Increasing loss of visual acuity
following exercise.
Central scotoma.
Normal findings upon ophthal-
moscopy (patient sees nothing;
examiner sees nothing).

Intraretinal linear hemorrhages:	Branch retinal vein occlusion.	Ophthalmoscopy (linear hemor-
In one quadrant	Hemispherical occlusion.	rhages).
In two quadrants	Central retinal vein occlusion.	Fluorescein angiography to
In four quadrants		differentiate ischemic from non-
		ischemic type.

Segmental or total visual field	Central retinal artery occlusion.	Ophthalmoscopy: whitish retinal
defects.		edema, visible “cherry red spot”
Sudden unilateral blindness.		(macula).

Symptoms Cardinal 19

545

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

Decreased visual acuity

Persisting longer than 24 hours, sudden onset, painless.

Patient is usually over 60.

Unilateral decrease in visual acuity.

Headaches.

Temporal artery is tender to palpation.

Cervical myalgia.

Pain when chewing.

Weight loss.

AION: anterior ischemic optic neuropathy due to arthritis in giant cell arthritis or temporal arteritis.

Risk of blindness.

Arterial biopsy and histologic examination are indicated.

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

Determine erythrocyte sedimentation rate and level of C- reactive protein (heightened levels in temporal arteritis).

Unequivocal diagnosis.

Slowly increasing over a period of weeks, months, or years; painless:

Gray to white pupillary reflex.	Cataract.	Slit-lamp examination. Diagnosis is
Loss of contrast.		unequivocal where the opacity is
Increased glare.		visible under retroillumination.

Corneal opacification.	Chronic corneal degeneration,	Unequivocal diagnosis.
Corneal scarring.	keratopathy.	Slit-lamp examination will reveal
		corneal degeneration and scar-
		ring.

Slow, painless:	Central visual field defect.	Age-related macular degenera-	Fluorescein angiography.
	Patient is usually over 65.	tion.
	Blurred vision, micropsia, and
	macropsia may be present.

	Increased intraocular pressure.	Primary chronic open angle glau-	Risk of blindness.
	Visual field defects	coma.	Measure intraocular pressure.
			Measure intraocular pressure.

Symptoms Cardinal 19 546

Decreased visual acuity is typically	Fuchs’ endothelial dystrophy.	Slit-lamp examination.
more severe in the morning than in
the evening.

Specifically decreased visual acuity	Myopia.	Test visual acuity.
in near or distance vision.	Hyperopia.

Painful, acute:	Whitish corneal opacification.	Acute keratoconus.
	Red eye, hard to palpation.	Glaucoma attack.
	Pupil fixed and dilated.
	Nausea, possible with vomiting.

Typical conical projection of the cornea is visible under slit-lamp examination.

Risk of blindness.

Measure intraocular pressure immediately.

Central scotoma.

Retrobulbar optic neuritis.

Neurologic examination.

Increasing loss of visual acuity following exercise; pain from posterior swelling and with eye motion.

Normal findings upon ophthalmoscopy (patient sees nothing; examiner sees nothing).

Combined injection.

Uveitis.

Slit-lamp examination.

Eye pain.

Fibrin and cells in the anterior chamber.

Vitreous infiltration.

Anterior and posterior synechiae.

547 Symptoms Cardinal 19

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

White pupillary reflex (leukocoria) in children

Often first noticed in photos

Retinoblastoma (whitish vitreous, retinal, or subretinal tumor) should be excluded in leukocoria.

Unilateral or bilateral.	Cataract.	Slit-lamp examination. Diagnosis is
		unequivocal where lens opacity is
		visible under retroillumination.

Up to 90% of patients are male	Coats’ disease.	Unequivocal diagnosis.
among children and teenagers.
Unilateral leukocoria (occa-
sionally combined with stra-
bismus).
Exudative retinal detachment
visible upon ophthalmoscopy.

Retinal detachment visible upon	Retinal detachment, for example	Unequivocal diagnosis.
ophthalmoscopy.	in retinopathy of prematurity.

Usually unilateral.	PHPV (persistent hyperplastic pri-	Ultrasound scan.
Congenital (leukocoria	mary vitreous).
manifests itself at birth).

Microphthalmos is usually present.

Usually unilateral (two-thirds of	Retinoblastoma (whitish vitreous,	Ophthalmoscopy also in fellow
all cases).	retinal, or subretinal tumor).	eye to exclude a bilateral retino-
May be accompanied by red		blastoma.
eye.		CT scan.

Child is usually below the age of three.

Globe is normal size.

Symptoms Cardinal 19 548

Blurred or distorted vision

Especially when fixating close or	Refraction anomaly (myopia or	Refraction testing.
remote objects.	hyperopia).

Older patients (65 and older).	Age-related macular degenera-	Ophthalmoscopy.
Gradual progressive loss of	tion.
visual acuity.

Patient under emotional of	Central serous chorioretinopathy.	Ophthalmoscopy.
physical stress.

Men in their thirties and forties are most commonly affected.

Objects appear enlarged or reduced in size.

Central relative visual field defects (patients see a dark spot).

Headaches, possibly with	Ocular migraine.	Unequivocal diagnosis.
nausea.Scintillating scotoma.

Permanent or worsening.	Cataract.	Slit-lamp examination will reveal
Possibly with diplopia.		obvious lens opacity where a cata-
Increased glare.		ract is present.
Gray to white pupillary reflex.

Narrowed or dilated pupil.	Following administration of eye-	Unequivocal diagnosis.
	drops (miotics or mydriatics).

Fundus reflex absent or weak.	Retinal detachment.	Neurologic examination.
Patient sees shadows (a “wall”		CT scan.
from below or a “curtain” from
above).

549 Symptoms Cardinal 19

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


Blurred or dis-	Headache.	Cerebral cause (tumor or increas-
torted vision	Visual field defect.	ed intracranial pressure).
	Diplopia.
	Ophthalmoplegia.
	Prominent, edematous optic
	disk.

Symptoms Cardinal 19 550

Appendix 1 Topical ophthalmic preparations

Pharmaceutical	Indications	Ocular effects and side effects	Systemic side effects

		Local irritation, keratitis, allergic reac-	No known systemic effects
Acyclovir	Herpes simplex keratitis.	Local irritation, keratitis, allergic reac-	No known systemic effects
	Herpes zoster ophthalmi-	tion in eyelids and conjunctiva.	from topical use.
	cus.

Atropine	Cycloplegia.	Mydriasis, angle closure glaucoma,	Confusion, tachycardia, dry
	Uveitis.	cycloplegia, decreased visual acuity,	mouth.
		increased intraocular pressure.

Beta blockers (timolol)	Glaucoma therapy.	Decreased intraocular pressure,	Bronchoconstriction, bradycar-
		decreased visual acuity, dry eye.	dia.

Carbachol	Glaucoma therapy.	Decreased intraocular pressure, miosis,	Fever, syncope, nausea.
		accommodation spasm, decreased
		visual acuity.

Clonidine	Glaucoma therapy.	Decreased intraocular pressure,	Decreased blood pressure.
		decreased blood supply to the head of
		the optic nerve.

Cyclopentolate	Mydriatic.	Mydriasis, angle closure glaucoma,	Central nervous system dys-
	Cycloplegic.	decreased visual acuity, increased	function, tachycardia, dry
		intraocular pressure.	mouth, nausea.

Chloramphenicol	Severe ocular bacterial infec-	Local irritation, keratitis, allergic reac-	Aplastic anemia (rare).
	tions.	tion in eyelids and conjunctiva, ker-
		atitis.

			Continued !

551 1 Appendix

Appendix 1 (Continued)

Pharmaceutical	Indications	Ocular effects and side effects	Systemic side effects

		Local allergic reaction in eyelids and	Malaise, depression, metallic
Dorzolamide (local	Glaucoma therapy.	Local allergic reaction in eyelids and	Malaise, depression, metallic
carbonic anhydrase	Prophylaxis against	conjunctiva.	taste.
inhibitor)	increased intraocular pres-
	sure following laser
	surgery.

Dipivefrin	Glaucoma therapy.	Decreased intraocular pressure, local	Tachycardia, cardiac arrhyth-
		irritation and allergic reaction in eyelids	mia, increased blood pressure,
		and conjunctiva, mydriasis, angle clo-	headaches.
		sure glaucoma.

Epinephrine	Glaucoma therapy.	Decreased intraocular pressure, cystoid	Headaches, perspiration, syn-
		macular edema.	cope.

Echothiophate	Glaucoma therapy.	Decreased intraocular pressure, miosis,	Nausea, dyspnea, bradycardia.
		decreased visual acuity, accommoda-
		tion spasm.

Gentamicin	Ocular bacterial infections,
	especially Pseudomonas aer-
	uginosa, Escherichia coli, Pro-
	teus species, Klebsiella pneu-
	moniae.

Local irritation and allergic reaction in	No known systemic effects
eyelids and conjunctiva, keratitis;	from topical use.
intravitreous administration may cause
retinal damage and atrophy of the
optic nerve.

Glucocorticoids	Anti-inflammatory therapy.	Increased intraocular pressure, poste-	Decreased plasma cortisol
		rior subcapsular cataract.	levels.

1 Appendix 552

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