Ординатура / Офтальмология / Английские материалы / Oxford American Handbook of Ophthalmology_Tsai, Denniston, Murray_2011

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Aids to diagnosis

648 CHAPTER 19 Aids to diagnosis

Acute red eye

Normal/near normal vision

Painful/discomfort

Diffuse superficial redness

•Conjunctivitis: infective, allergic, or chemical; gritty/itchy; watery, mucoid, mucopurulent, or purulent exudate; papillae or follicles.

Diffuse deep redness

•Anterior scleritis: severe pain; diffuse deep injection that does not blanch with vasoconstrictors (e.g., phenylephrine 10%), scleral edema; scleral thinning; lid edema; globe tenderness, pain with eye movement.

Circumlimbal redness

•Keratitis: photophobia, watery eye, circumlimbal injection, corneal infiltrate ± epithelial defect ± AC activity.

•Anterior uveitis: photophobia, watery eye, keratic precipitates, AC activity, ± posterior synechiae.

•Corneal foreign body: appropriate history, FB sensation, visible FB, rust ring.

Sectoral redness

•Episcleritis: mild discomfort; may be recurrent; sectoral (occasionally diffuse) redness that blanches with topical vasoconstrictor (e.g., phenylephrine 10%); globe nontender.

•Marginal keratitis: photophobia, watery eye, marginal corneal infiltrate

± epithelial defect in large persistent keratitis.

Painless

• Subconjunctival hemorrhage: well-defined confluent area of hemorrhage.

Reduced vision

Normal IOP

Abnormal corneosclera

•Corneal abrasion: photophobia, watery eye, sectoral/circumlimbal injection, epithelial defect.

•Keratitis: photophobia, watery eye, circumlimbal injection, corneal infiltrate ± epithelial defect ± AC activity ± mucopurulent discharge.

Abnormal uvea

•Anterior uveitis: photophobia, watery eye, keratic precipitates, AC activity, ± posterior synechiae.

•Endophthalmitis: pain, floaters, watery eye, diffuse deep injection, inflammation (vitreous > AC), chorioretinitis, hypopyon.

iIOP

•Acute glaucoma: usually due to angle closure; photophobia, watery eye, corneal edema, ± anterior segment/angle abnormalities such as rubeosis.

•Hypertensive uveitis: anterior chamber cells and flare ± corneal involvement; often due to herpes group of viruses with sectoral iris atrophy.

SUDDEN OR RECENT LOSS OF VISION 649

Sudden or recent loss of vision

Painless

Few seconds duration

Unilateral

•Giant cell arteritis: usually age >55 years, weight loss, fatigue, jaw or tongue claudication, pulseless, tender, or thickened temporal artery, raised ESR, CRP.

•Papilledema: bilateral optic disc swelling, loss of spontaneous venous pulsation (SVP), peripapillary hemorrhages, features of raised ICP.

•Impending central retinal vein occlusion: dilated, tortuous retinal veins, hemorrhages.

•Ocular ischemic syndrome: veins dilated and irregular but not tortuous, midperipheral hemorrhages; ± NVD, dIOP, carotid bruits.

Bilateral

• Papilledema: see above.

Few minutes duration

Unilateral

•Amaurosis fugax: curtain across vision ± evidence of emboli, atrial fibrillation, carotid bruits.

•Giant cell arteritis: see above.

Bilateral

•Vertebrobasilar artery insufficiency: recurrent episodes ± ataxia, dysphasia, dysarthria, hemiparesis, hemisensory disturbance.

Up to 1 hour duration

•Migraine: fortification spectra, transient VF defects, unilateral headache, nausea/vomiting, photophobia, aura, family history.

Persistent

Abnormal cornea

•Hydrops: acute corneal edema associated with underlying disease such as keratoconus.

Abnormal vitreous

•Vitreous hemorrhage: varies from microscopic level to completely obscuring the fundus.

Abnormal fundus

•Central retinal artery occlusion: RAPD, attenuated arterioles, box carring of retina vessels, pale fundus, cherry-red spot.

•Central retinal vein occlusion: dilated tortuous veins, hemorrhages in all four quadrants, ± cotton wool spots, retinal edema, RAPD. Branch retinal vein occlusions may give symptomatic altitudinal defects, particularly if on temporal arcade.

•Rhegmatogenous retinal detachment: flashes/floaters, tobacco dust, corrugated elevated retina with (multiple) break(s).

650CHAPTER 19 Aids to diagnosis

•Exudative retinal detachment: convex elevated retina with shifting fluid, no break; tractional: concave elevated retina with tractional membranes.

•Intermediate uveitis: floaters, vitritis, snowballs/banking ± macular edema, optic nerve edema.

•Posterior uveitis: floaters, significantly reduced vision; vitritis, retinal/ choroidal infiltrates, macular edema, vascular sheathing or occlusion, hemorrhages.

Abnormal optic disc

•Anterior ischemic optic neuropathy: RAPD, pale edematous disc ± flameshaped hemorrhages; may have altitudinal field defect; may be arteritic (with signs of giant cell arteritis) or nonarteritic (usually sectoral).

Abnormal macula

•Choroidal neovascular membrane: distortion ± positive scotoma, drusen, subretinal membrane ± hemorrhage, exudate.

•Central serous retinopathy: color desaturation, micropsia, serous detachment of neurosensory retina.

Normal fundus

•Cortical blindness: ± denial, small residual field; normal pupil reactions; abnormal CT/MRI head.

•Functional: inconsistent acuity between different tests and at different times, normal ophthalmic examination, normal electrodiagnostic tests.

Painful

Abnormal cornea

•Acute angle closure glaucoma: usually hypermetropic, halos, frontal headache, vomiting; injected, corneal edema, fixed semidilated pupil, shallow anterior chamber with closed angle, raised IOP.

•Bullous keratopathy: thickened, hazy cornea, stromal or subepithelial edema, bullae, evidence of underlying pathology (e.g., ACIOL, Fuchs’ endothelial dystrophy).

•Keratitis: photophobia, watery eye, circumlimbal injection, corneal infiltrate ± epithelial defect ± AC activity.

Abnormal optic disc

•Optic neuritis: usually age 18–45 years, with retro-orbital pain, especially on eye movement, RAPD, reduced color vision, visual field defects, swollen optic disc ± peripapillary flame-shaped hemorrhages. It may also be painless.

Abnormal uvea

•Anterior uveitis: anterior: pain, photophobia, mildly reduced vision, circumlimbal injection, anterior chamber cells and flare, keratic precipitates.

Normal fundus

•Retrobulbar neuritis: as for optic neuritis but with a normal optic disc. It may also be painless.

GRADUAL LOSS OF VISION 651

Gradual loss of vision

Generalized

Abnormal cornea

•Corneal dystrophies: corneal clouding (deposition/edema); usually bilateral but may be asymmetric. Common types include Fuchs’ endothelial dystrophy in the elderly, and Reis–Buckler’s dystrophy in young adults.

•Keratoconus: refractive error from progressive astigmatism; corneal edema and scar from acute hydrops; usually bilateral but may be asymmetric.

Abnormal lens

•Cataract: unior bilateral opacification of the lens; cloudy, misty; glare. This is most common in the elderly.

Central

Abnormal macula

Macular disease usually leads to distortion ± micropsia and early dVA; pupillary responses and color vision are relatively preserved. Common causes include the following:

•Age-related macular degeneration: very common bilateral disease of the elderly. The most common type involves dry changes, which are associated with gradual patchy central loss.

•Macular dystrophies: group of diseases with specific patterns occurring in younger age group; bilateral disease. Patients may have a family history of it, and genetic testing is sometimes possible.

•Diabetic maculopathy: ischemia may lead to gradual dVA; edema may lead to more acute distortion/dVA. It is associated with other diabetic changes.

•Cystoid macular edema: edema resulting in distortion/dVA may be associated with surgery, inflammation, or vascular disease.

Abnormal optic disc or nerve

Optic nerve disease usually leads to dimness and darkening of colors. Although commonly affecting central vision, it may lead to peripheral or generalized loss of vision. Pupillary responses, color vision, and brightness testing are all reduced. Important causes include the following:

•Compressive optic neuropathy: progressive dVA, optic disc pallor ± pain, involvement of other local structures.

•Leber’s hereditary optic neuropathy: severe sequential dVA over weeks or months, telangiectatic vessels around disc (acutely); usually young adult males; family history mitochondrial inheritance.

•Toxic or nutritional optic neuropathies: slowly progressive symmetrical dVA with central scotomas; relevant nutritional, therapeutic, or toxic history.

652CHAPTER 19 Aids to diagnosis

•Inflammatory optic neuropathies: associated with systemic disease (e.g., sarcoid, vasculitis, and syphilis). They are often very steroid sensitive.

•Chronic papilledema: sustained optic disc swelling due to raised intracranial pressure may cause permanent optic nerve dysfunction, including dVA and field defects, and optic disc pallor.

Peripheral or patchy

Abnormal choroid/retina

•Posterior uveitis: floaters, patchy loss of vision ± central distortion/dVA from CME; may include chorioretinitis, vitritis, retinal vasculitis.

•Retinitis pigmentosa: bilateral concentric peripheral field loss, peripheral “bone-spicule” pigmentation, retinal arteriole attenuation, and optic disc pallor.

Abnormal optic disc

•Glaucoma: asymptomatic peripheral field loss; usually bilateral but often asymmetric; characteristic optic disc cupping and other disc changes; often associated with iIOP.

654 CHAPTER 19 Aids to diagnosis

Flashes and floaters

Flashes only

Retinal traction

This involves vitreoretinal traction, proliferative diabetic retinopathy, sickle cell retinopathy, and retinopathy of prematurity.

Pseudoflashes

Ocular

•Photophobia: discomfort commonly associated with anterior segment inflammation or retinal hypersensitivity.

•Glare: visual symptom commonly associated with media opacities.

•Halos: ring effect associated with corneal edema and some media opacities.

CNS

•Papilledema: transient, associated with straining or change in posture.

•Migraine: classic enlarging zig-zag fortification spectra moving central to peripheral, usually followed by headache.

•Occipital lobe lesions (tumors, AVMs): colored shapes and blobs.

•Other visual hallucinations: bilateral severe visual loss may result in more complex visual hallucinations (Charles Bonnet syndrome).

Floaters only

•Posterior vitreous detachment: partial or complete Weiss ring overlying the optic disc ± visible posterior vitreous face.

•Vitreous condensations: degenerative changes within the vitreous lead to translucent opacities.

•Vitreous hemorrhage: red cells in the vitreous, varies from minor bleed (spots in vision, fundus easily visualized) to severe (profound dVA, no fundus view); may be followed by synchysis scintillans (golden particles that settle with gravity).

•Vitritis: white cells in the vitreous, may be bilateral and associated with features of intermediate or posterior uveitis.

•Asteroid hyalosis: small yellow-white particles that move with the vitreous (rather than settling with gravity), usually innocuous.

•Amyloidosis: sheet-like opacities, usually bilateral; most commonly seen with familial systemic amyloidosis.

•Tumors (e.g., choroidal melanoma, lymphoma): vitritis of inflammatory and/or tumor cells may be seen.

Flashes and floaters

•Posterior vitreous detachment: partial or complete Weiss ring overlying the optic disc ± visible posterior vitreous face.

•Retinal tear: usually horseshoe tear and pigment in the vitreous. It may be associated with vitreous hemorrhage or retinal detachment.

•Retinal detachment: usually rhegmatogenous (associated with a tear) resulting in elevated retina with subretinal fluid.

•Tumors: visual phenomena include slow moving ball of light and floaters secondary to tumor cells or inflammation associated with a choroidal or retinal mass.

HEADACHE 655

Headache

Swollen optic discs

Bilateral

Serious or life-threatening headaches

•Raised intracranial pressure: worsening headache on lying flat, coughing, sneezing, or Valsalva maneuver; visual obscurations; diplopia, disc swelling with loss of SVP; blind spot enlargement; CN VI palsy. Causes include the following:

•Cerebral tumor, idiopathic intracranial hypertension, venous sinus thrombosis, meningitis, encephalitis, brain abscess, congenital ventricular abnormalities, cerebral edema.

•Subarachnoid hemorrhage: thunderclap headache, meningismus, altered consciousness.

•Accelerated hypertension: hypertensive retinopathy including cottonwool spots (CWS), retinal hemorrhages, exudates, optic nerve edema, arterial occlusion and capillary closure.

Unilateral

Serious or life-threatening headaches

•Giant cell arteritis: usually age >55 years; visual loss, scalp tenderness (± necrosis), jaw or tongue claudication, limb girdle pain and weakness, fevers, weight loss; nonpulsatile, tender, thickened temporal arteries. AION results in unilateral or, less commonly, bilateral optic disc swelling.

No optic disc swelling

Serious or life-threatening headaches

•Raised intracranial pressure may occur in the presence of nonswollen discs (e.g., myopic discs, atrophic discs, anomalies of the optic nerve sheath).

•Giant cell arteritis: see above.

•Pituitary adenoma: endocrine dysfunction (amenorrhea, galactorrhea, infertility, acromegaly, Cushing’s disease; optic atrophy; bitemporal field loss).

•Pituitary apoplexy: recent major hypotensive episode (e.g., surgery, postpartum hemorrhage); acute dVA, meningism, dLOC.

Headache syndrome

•Tension headache: very common; tightness, bifrontal, bioccipital, or band-like; may radiate to neck; headache-free intervals; no neurological or systemic features. This may be associated with cervical spondylosis.

•Migraine: common; prodrome, headache (usually hemicranial), nausea, photophobia, phonophobia. Visual phenomena include scintillating visual aura (starts paracentral and expands as it moves peripherally), transient visual loss (unilateral or homonymous hemifield), or ophthalmoplegia.

•Cluster headache: sudden oculotemporal pain, no prodrome, may have transient lacrimation, rhinorrhea, and Horner’s syndrome.