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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 13 Neurological signs
312
Ophthalmoscopic findings in the
diabetic patient
The red-free or green light of the ophthalmoscope is very useful for
detecting retinopathy. Use serial visual-acuity measurements to detect
early maculopathy.
Some differential diagnoses and typical outline evidence
Diabetic
cataract
Suggested by: gradual visual loss in a diabetic
Confirmed by: ophthalmoscopic appearance
Diabetic
glaucoma
Suggested by: pale, deeply cupped disc with sharp
margins
Confirmed by: ophthalmoscopic appearance and
visual-field test. Raised intraocular pressure
Diabetic
microaneurysm
and bleeding
into retina
Suggested by: dots (microaneurysms or deep
hemorrhages) and blots or flames (deep and superficial
hemorrhages)
Confirmed by: regular retinal photography for progress
Venous
irregularity
preceding
hemorrhage
Suggested by: localized widening of veins (e.g., sausage-
shaped veins)
Confirmed by: regular retinal photography for progress
Diabetic hard
exudates
Suggested by: round and small pale area (after a single
serous leak), circular with central red dot (indicating a
continuous leak), enlarging circle with time
Confirmed by: regular retinal photography for progress
Diabetic
macular
exudates
(leading to
visual loss)
Suggested by: star-shaped pallor (as the exudates
follow the radial nerve fiber arrangement) and loss of
visual acuity
Confirmed by: regular retinal photography for progress
OPHTHALMOSCOPIC FINDINGS IN THE DIABETIC PATIENT1
313
Diabetic soft
exudates
(nerve fiber
infarct preceding
new vessels)
Suggested by: pale gray area with indistinct margins
Confirmed by: regular retinal photography for progress
Diabetic new
vessel
formation
(leads to
hemorrhage)
Suggested by:
“frond” growing forward into the
vitreous (seen by adjusting focus) or like a net
growing on the surface of the retina, arising from disc
or larger peripheral veins
Confirmed by: three-dimensional clinical appearance
Retinal
hemorrhage and
detachment
Suggested by: subhyaloid hemorrhage obscuring
underlying vessels, often forming nest shape—flat
top and round bottom
Confirmed by: three-dimensional clinical appearance
Vitreous
hemorrhage
Suggested by: sudden loss of vision in a diabetic and a
poor red reflex on ophthalmoscopy
Confirmed by: retinal photography
Retinal vein
occlusion
Suggested by: sudden vision loss, often in upper or
lower half only
Confirmed by: extensive superficial retinal hemorrhages
following the nerve fiber layer, which may be in only
the upper or lower half of the retina
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CHAPTER 13 Neurological signs
314
Ophthalmoscopic findings in the
hypertensive patient
Some differential diagnoses and typical outline evidence
Grade I
hypertensive
retinopathy
Suggested by: raised blood pressure on 3 occasions,
typically >90 mmHg diastolic or >140 mmHg systolic
Confirmed by: segmental narrowing and tortuosity of
arteries
Grade II
hypertensive
retinopathy
Suggested by: moderately raised blood pressure
on 3 occasions, typically >100 mmHg diastolic or
>160 mmHg systolic
Confirmed by: segmental narrowing and tortuosity of
arteries and arteriovenous (AV) nicking
Grade III
hypertensive
retinopathy
Suggested by: severely raised blood pressure
on 3 occasions, typically >120 mmHg diastolic or
>180 mmHg systolic
Confirmed by: segmental narrowing and tortuosity
of arteries and AV nicking and hemorrhages and
exudates
Grade IV
hypertensive
retinopathy
Suggested by: severely raised blood pressure, typically
>140 mmHg diastolic or >200 mmHg systolic
Confirmed by: segmental narrowing and tortuosity
of arteries and AV nicking and hemorrhages and
exudates and papilledema
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CHAPTER 13 Neurological signs
316
Loss of central vision and acuity only
Visual acuity is tested in each eye with a Snellen chart at 20 feet:
20/20 = 100% acuity (actually, a reference point, not “normal”), and 20/40
= 50% acuity (letters readable by a person with 20/20 acuity at 20 feet
only visible at 10 feet).
Fields are tested by facing patient and having the patient close match-
ing eyes. Wag your finger, moving in from the periphery horizontally and
diagonally, changing hands. Test for scotoma with red marker-pen top,
moving horizontally and asking for change of color and disappearance. The
rate of onset is important; sudden loss of vision is an emergency.
Acute onset of visual loss
Optic nerve
swelling or
(eventually)
atrophy
(due to papillitis
from MS, or
papilledema or
optic nerve
infarction in
temporal
arteritis and
retinal artery
occlusion)
Suggested by: raised pink optic disc with blurred
margins 9 distended capillaries, and adjacent streak
hemorrhages progressing to pale white disc with pale
margins. Gradual loss of vision after initial disturbance
Confirmed by: visual-field mapping. Ophthalmoscopic
appearance
Temporal/giant
cell or cranial
arteritis
Suggested by: scalp tenderness, jaw claudication, loss of
temporal arterial pulsation, sudden loss of vision, iiESR
Confirmed by: temporal artery biopsy (may be done
shortly after starting corticosteroids)
Retinal artery
occlusion
Suggested by: sudden loss of vision. May be total or
partial upper or lower field
Confirmed by: in the first few days, retinal pallor. Later,
a white, thready, thin artery
Retinal vein
occlusion
Suggested by: sudden vision loss, often in upper or
lower half only
Confirmed by: extensive superficial retinal hemorrhages
following the nerve fiber layer, which may be in only
the upper or lower half of the retina
Vitreous
hemorrhage
Suggested by: sudden loss of vision in a diabetic and a
poor red reflex on ophthalmoscopy
Confirmed by: retinal photography
LOSS OF CENTRAL VISION AND ACUITY ONLY1
317
Gradual onset of visual loss
Cataract
(due to ageing
[75%], diabetes,
trauma, steroids,
radiation,
intrauterine
rubella or
toxoplasmosis,
or rubella,
hypocalcemia)
Suggested by: gradual onset of visual blurring and lens
opacity visible during red reflex examination with the
ophthalmoscope. Usually >65 years of age or history
of underlying condition (often already known and
cataract develops later)
Confirmed by: opthalmoscopic appearance
Macular
degeneration
(age-related)
Suggested by: gradual loss of central vision, large,
central, yellowish white scar or hemorrhage when
patient looks at ophthalmoscope light
Confirmed by: ophthalmoscopic appearance
Choroidoretinitis Suggested by: gradual loss of vision, or blurring
(in acute phases), and patchy visual loss—scotomata
Confirmed by: visual-field mapping showing irregular
patchy areas of visual loss. Corresponding areas in the
eye of irregular depigmentation with dense areas of
pigment in the center.
Tests results for underlying cause: CXR, serology,
sputum, lung biopsy
Glaucoma Suggested by: gradual loss of vision, deeply cupped disc
Confirmed by: ophthalmoscopic appearance of deep
cupping with visible cribriform plate and nasal
displacement of vessels. Loss of peripheral field.
Raised intraocular pressure
Primary optic
atrophy
(prior inflamma-
tion not seen; due
to MS or optic
nerve infarction)
Suggested by: gradual visual loss in a quiet eye and
pale disc with sharp margins
Confirmed by: ophthalmoscopic appearance of pale
white, featureless disc and may have thin, thready
vessels
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CHAPTER 13 Neurological signs
318
Peripheral visual-field defect
An upper or lower half defect is due to ocular pathology. Lesions
between eye and chiasm cause unilateral defects but those from chiasma
to brain are homonymous, i.e., affecting same area in each eye.
Some differential diagnoses and typical outline evidence
Psychogenic field
defect
Suggested by: tunnel vision (same diameter at all
distances). Normal optic disc, visual acuity and color
vision
Confirmed by: no progression on follow-up
Retinitis
pigmentosa
Suggested by: tunnel vision with good visual acuity in
light, but inability to navigate around objects and
virtually blind in the dark
Confirmed by: pale, atrophic disc, thin, thready
vessels, and asterisk or reticular type pigment in
the retina without pale patches of depigmentation.
Visual-field mapping
Choroiditis
(choroidoretinitis)
(due to TB, sarcoid
toxoplasmosis,
toxacara)
Suggested by: gradual loss vision or blurring (in acute
phases), gray–white raised patch on retina, vitreous
opacities, muddiness in the anterior chamber, then
white patch with pigmentation around on retina
(choroidoretinal scarring)
Confirmed by: tests results for underlying cause: CXR,
serology, sputum, lung biopsy
Optic chiasm
lesion
(due to
pituitary tumor,
craniopharyngioma,
aneurysm)
Suggested by: bitemporal hemianopia (or sometimes
bitemporal upper quadrantinopia from tumor
pushing up)
Confirmed by: visual-field mapping. CT or MRI scan
appearance
Optic tract lesion
(due to middle
cerebral artery
thrombosis of
contralateral side)
Suggested by: homonymous hemianopia
Confirmed by: visual-field mapping. MRI scan
appearance
Visual cortex
lesion
(due to posterior
cerebral artery
occlusion,
tumor)
Suggested by: homonymous hemianopia or,
occasionally, quadrantanopia. May have macular
sparing (visual acuity normal). Tunnel vision if
bilateral
Confirmed by: visual-field mapping. CT or MRI scan
appearance
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CHAPTER 13 Neurological signs
320
Ptosis (drooping of one or both upper
eyelids)
Some differential diagnoses and typical outline evidence
Oculomotor
(third-nerve)
lesion
due to pituitary
tumor,
intracavernous or
posterior
communicating
artery aneurysm,
meningioma,
tentorial
pressure cone
diabetes mellitus,
syphilis, and brain
stem ischemia
Suggested by: ptosis, diplopia, and squint maximal on
looking up and in. But in total loss, eye looks down
and out. Dilated pupil (except in diabetes mellitus,
syphilis, and brain stem ischemia when pupil not
dilated); other cranial nerve lesions that form pattern
(see p. 332)
Confirmed by: CT or MRI scan appearance
Horner’s
syndrome
due to neck
trauma or
tumors, cervical
rib, Pancoast
tumor (in lung
apex) syringo-
myelia (in cervical
spine), lateral
medullary
syndrome
(in brain stem),
hypothalamic
lesion
Suggested by: ptosis and constricted (miotic) pupil,
recessed globe of the eye, and diminished sweating
on same side of face
Confirmed by: history of trauma or onset over week or
months suggestive of tumor, or years suggestive of MS
or syrinx. Other cranial nerve signs that form pattern
of cervical plexus lesion or brain stem lesion. X-ray of
upper chest, ribs, or neck. CT of neck or upper chest
or MRI scan of brain stem
Myasthenia
gravis
Suggested by: bilateral partial ptosis worsening as day
progresses
Confirmed by: eyes begin to droop after 15 minutes of
up-gaze. Positive Tensilon test (edrophonium results in
improvement in ptosis)
PTOSIS (DROOPING OF ONE OR BOTH UPPER EYELIDS)1
321
Myopathy
(dystrophia
myotonica)
Suggested by: bilateral partial ptosis with evidence of
weakness in other muscle groups. Frontal balding,
inability to release hand grip
Confirmed by: biopsy histology of other affected
muscle
Congenital
ptosis
Suggested by: unilateral or bilateral partial ptosis
present since birth. Compensatory head posture
Confirmed by: absence of other neurological signs
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