|CHAPTER||27||Ocular Symptoms and Examination|
Ocular symptoms can be categorized as follows:
•Symptoms due to ocular surface anomalies.
•Symptoms caused by anomalies of ocular motility.
■Symptoms due to Ocular Surface Anomalies
Diseases affecting ocular surface (i.e., conjunctiva and cornea) present with symptoms like red eye, foreign body sensation, ocular irritation or burning, photophobia (light sensitivity), discharge, and itching (itchy eyes).
It is a symptom of anterior segment diseases. It has multiple causes as mentioned below:
•Conjunctivitis (due to any cause).
•Conjunctival foreign body.
•Toxic or chemical reaction.
•Corneal foreign body.
•Recurrent corneal erosions.
•Infectious keratitis (due to any cause).
•Chemical or UV burn.
•Dry eye syndrome.
•Pharmacologic (prostaglandin analogues, miotics and other vasodilatory medication, and brimonidine).
Foreign Body Sensation
It may be due to:
•Dry eye syndrome.
•Foreign body (conjunctival or corneal).
•Recurrent corneal erosions.
•Superficial punctate keratopathy (SPK).
•Contact lens-related problems.
Ocular Irritation or Burning
Patient may complain of burning or gritty sensations in the eyes which may be caused by:
•Dry eye syndrome.
Photophobia (Light Sensitivity)
It is the inability to tolerate light and causes discomfort or pain to the eyes due to light exposure. It may be found without visible ocular diseases or may be associated with ocular diseases.
In ocular diseases: Nearly all inflammatory diseases of eye have an associated photophobia, for example:
•Cornea: Abrasion, edema, foreign body, and ulcer.
•Uvea: Anterior uveitis.
•Mydriasis due to drugs or trauma.
•Acute angle-closure glaucoma.
•Total color blindness (achromatopsia).
Without visible ocular disease: If photophobia is present with normal eye examination, patient should be investigated for the following:
•Retrobulbar neuritis (RBN).
It may be:
It is seen in different types of inflammations, for example, conjunctivitis, keratitis (corneal ulcers), stye, blepharitis, meibominitis, dacryocystitis, etc.
Itching (Itchy Eyes)
Itching may be due to:
•Topical drug allergy or contact dermatitis.
•Giant papillary conjunctivitis.
Common visual symptoms include diminution of vision, distortion of vision (metamorphopsia), micropsia, colored halos, floaters (spots in front of the eyes) and photopsia (flashes of light), glare (excessive awareness of light), diplopia (Double vision), night blindness (nyctalopia), day blindness (hemeralopia), and color blindness.
Diminution of Vision
It is one of the commonest complaints of an ophthalmic patient. It may be:
•Sudden or gradual.
•Transient or permanent.
•Painless or painful.
•Unilateral or bilateral.
•Progressive or stationary.
So, patient is always asked the following questions related to decreased vision (Flowchart 27.1):
•Onset: Whether it is sudden or gradual?
•Duration: If the diminution of vision is transient and returns to normal within 24 hours, usually within 1 hour or it lasts longer than 24 hours?
•Progression: Ask the patient whether the diminution of vision is static, steadily worsening, or improving?
•Pattern: Whether it is constant or intermittent?
•Frequency of occurrence: Whether it is episodic or periodic?
•Unilateral (U/L) or Bilateral (B/L): If bilateral, were both the eyes affected simultaneously or sequentially?
•Whether it is more for distance or nearness?
•If the diminution of vision is associated with pain or it is painless?
•Ask about the associated symptoms such as redness, watering, photophobia, floaters, and diplopia.
Generally, the posterior segment conditions are associated with painless diminution of vision.
Causes of sudden and painless diminution of vision are:
•Unilateral: It is seen in:
◊Retinal vein occlusion.
◊Retinal artery occlusion.
◊Central serous retinopathy (CSR).
•Bilateral: It is due to:
◊Bilateral occipital infarction.
◊Toxic optic neuropathy.
Causes of sudden painful diminution of vision are:
•Acute anterior uveitis.
•Acute angle-closure glaucoma.
•RBN: Diminution of vision is associated with pain on eye movements.
•Ocular injury (mechanical, chemical, or thermal).
Causes of gradual, painless and progressive diminution of vision are:
•Age-related macular degeneration (ARMD)—dry type
•Inferior retinal detachment: Subretinal fluid detaches the retina against gravity. So, detachment occurs gradually causing marked diminution of vision.
•Hereditary macular degeneration.
Causes of gradual painful diminution of vision are:
•Chronic anterior uveitis.
•Corneal dystrophy causing corneal edema.
•Aphakic/pseudophakic bullous keratopathy.
Cause of transient diminution of vision is amaurosis.
It is the vision loss or weakness that occurs without an apparent lesion affecting the eye. It may affect one or both the eyes. It is due to temporary lack of blood flow either to retina or the brain. Its causes are as follows:
•Amaurosis fugax: It is unilateral loss of vision due to transient ischemic attack lasting few minutes to 1–2 hours.
•Vertebrobasilar artery insufficiency–
•Migraine: With or without a subsequent headache.
•Giant cell arteritis.
•Impending central retinal vein occlusion (CRVO).
•Carotid occlusive disease (atherosclerosis of carotid artery).
•Functional (hysteria and malingering).
It is the transient unilateral loss of vision in a particular direction of the eccentric gaze. It is pathognomonic of orbital disease, for example, optic nerve sheath meningioma. Orbital disease causes compression of optic nerve leading to transient optic nerve ischemia which, in turn, causes transient blurring of vision.
Defective vision for distance is seen in myopia and nuclear sclerosis, while defective vision for near is seen in presbyopia, hypermetropia, and cycloplegia.
Distortion of Vision (Metamorphopsia)
In metamorphopsia, patient perceives irregular and distorted shape of objects. It can be reviewed with the Amsler grid. It is associated with diseases affecting macula, for example:
•Diabetic macular edema.
When the retinal elements (cones) at fovea get separated due to collection of subretinal fluid, the objects look smaller than normal. This is termed micropsia and it is seen in CSR.
These are the rings of rainbow color around lights at night. It is associated with angle-closure glaucoma, corneal edema, and incipient or early cataract. Due to accumulation of fluid in all these conditions, refractive condition of the eye alters, causing prismatic dispersion of light. This leads to formation of colored halos with red outside and blue innermost.
Halos due to incipient cataract and corneal diseases may be differentiated by the Fincham test. During this test, a stenopeic slit is passed before the eye across the line of vision. Glaucomatous halo (due to corneal edema) remains intact but lenticular halo is broken up into segments. These segments revolve with the movement of the slit.
Floaters (Spots in Front of the Eyes) and Photopsia (Flashes of Light)
Normal vitreous is a transparent gel attached to the retina at places. Two changes, liquefaction and shrinkage, occur (due to age or any other cause) in vitreous (Flowchart 27.3).
If photopsia is accompanied by floaters, look for peripheral retinal degeneration by indirect ophthalmoscope, which may be prone to retinal tear after retinal traction.
Glare (Excessive Awareness of Light)
It is excessive awareness to the light within the field of vision which is brighter than the brightness to which the eyes are adapted.
•Conditions which allow excess light to enter the eye:
•Conditions which produce excessive scattering of light in the eye:
◊Posterior subcapsular cataract.
◊Posterior vitreous detachment.
Diplopia (Double Vision)
It may be monocular or binocular.
Monocular diplopia: It is the subjective perception of two images of an object with one eye (either eye). It remains when the uninvolved eye is occluded. It is found in:
•Dislocation of lens (two images are perceived; one through the aphakic zone and other through the phakic zone).
Binocular diplopia: It is the perception of two images of an object with both eyes open. It is eliminated when either eye is occluded. It is due to the loss of synchronous movement of both eyes and may be intermittent or constant.
Polyopia means multiple images are seen and it may happen due to cataract.
Night Blindness (Nyctalopia)
It is due to the interference with the functions of retinal rods. It is seen in:
•Vitamin A deficiency in children.
•Pigmentary retinal dystrophy (retinitis pigmentosa).
Day Blindness (Hemeralopia)
It is due to:
•Congenital cone deficiency.
•Central cataract (posterior subcapsular cataract).
Color blindness is either congenital or acquired; both the types could be partial or complete.
Complete Congenital Color Blindness
It is rare and generally caused by a central defect. All colors appear gray but with differing brightness.
Partial Congenital Color Blindness
It is inherited as X-linked recessive trait, so it is more common in males than females. Three types of photopigments (sensitive for red, green, and blue colors) are found in foveal cones and the absence of one of the photo pigments results in partial congenital color blindness. The red and green defect is more common, while the absence of blue sensation is very rare.
In protanopes the red sensation is defective; in deuteranopes, the green sensation is defective, while in tritanopes, the blue sensation is absent. If the defect is not complete, then these are called protanomalous, deuteranomalous, and tritanomalous respectively.
■Symptoms due to Anomalies of Ocular Motility
These include eyestrain or asthenopia, binocular diplopia, “jumping” eyes, and deviation of eyes.
It is defined as fatigue of the eyes commonly following prolonged close work and watching TV or film. It increases toward the evening. Symptoms of eyestrain may be absent if near work is avoided. Asthenopic symptoms (eyestrain) include eye ache, burning, watering, frontal headache, and eye fatigue.
Asthenopia is generally due to the following causes:
•Extraocular (EOM) muscle imbalance.
•Uncorrected refractive error.
•Incorrect refractive correction.
Inadvertent rubbing of eyes (due to eye strain) with dirty fingers may result in recurrent stye, chalazia, or blepharitis.
It is the perception of two images of an object with both eyes open. It is eliminated when either eye is occluded. It is due to the loss of synchronous movement of both eyes and may be intermittent or constant.
Intermittent binocular diplopia is seen in myasthenia gravis and intermittent decompensation of existing phoria.
Constant binocular diplopia is seen in:
•EOM paresis (isolated 6th, 3rd, or 4th nerve palsy).
•Thyroid eye disease (due to restrictive movements).
•Orbital wall fracture with EOM entrapment.
It includes presenting complaints, history of illness, occupation and past and family history.
Chief Presenting Complaints
All the complaints of the patients must be recorded before starting the ocular examination. The common complaints of the patient are:
•Defective vision (for distance, near or both).
•Discharge from the eyes.
•Foreign body sensation.
•Deviation of eye.
•Black spots in front of eyes.
History of Present Illness
•Enquire about the mode of onset (acute or insidious) and duration of the ailment.
•Progression of the complaint (whether it is stationary/improving/worsening).
•Nature of discharge (watery/mucopurulent/purulent/ropy/sanguinous).
•Ask about the association of itching and climate/season.
Information about the patient’s occupation is helpful because of occupational hazards (Table 27.1).
Table 27.1 Important occupational hazards
•Computer vision syndrome
•Ocular injuries and trauma
Patient must be asked about:
•Trauma in the past (for posterior subcapsular cataract and retinal detachment).
•Past medical and surgical history.
•History of similar ocular complaints in the past (for recurrent diseases such as uveitis, herpes simplex keratitis, and recurrent corneal erosions).
•History of systemic illness, for example, diabetes, hypertension, thyroid dysfunction, and joint pains.
Family history is important as certain ocular diseases are genetically transmitted such as:
Maternal history regarding any infection (toxoplasmosis, rubella, venereal disease, herpes infection, and HIV infection), drug abuse, smoking, tobacco chewing, alcohol, and sexual history must be taken during the first trimester of pregnancy.
■Examination of the Eye (Outline)
It is examined by the slit-lamp biomicroscope (with or without +90D), direct ophthalmoscope, retinoscope, indirect ophthalmoscope, and Goldmann 3-mirror contact lens. The examination of the eye requires:
•Testing of visual acuity (both for distance and near).
•Examination of head posture (in patients afflicted with strabismus, particularly vertical muscles palsies to avoid diplopia).
•Examination of forehead for wrinkling:
◊Present due to over action of frontalis muscle as in ptosis.
◊Absent on one side in lower motor neuron facial palsy.
•Examination of eyelids for their position, movement, lid crease, lid margins (entropion/ectropion), and direction of eye lashes.
•Examination of palpebral aperture: It measures 28 to 30 mm horizontally and approximately 10 mm vertically in the center. Narrow palpebral aperture is seen in blepharospasm or inflammatory conditions of conjunctiva/cornea. Wide palpebral aperture is seen in retraction of upper lid (upper limbus is visible), proptosis (lower limbus is exposed), facial nerve palsy, and buphthalmos.
•Examination of eye balls for:
◊Their position (proptosis or enophthalmos).
◊Their movements (restricted in paralytic strabismus or fibrosis).
◊Position of eye balls (for strabismus).
◊Rhythmic oscillations (nystagmus), indicating that fixation reflex is not well-developed.
•Examination of lacrimal apparatus:
◊Lacrimal sac is inspected for swelling (dacryocystitis) or any fistula.
◊Inspection of lacrimal gland for its size (enlarged in inflammatory and neoplastic conditions).
◊Look for lower puncta for its patency/obstruction/narrowing/eversion/any foreign body such as eyelash obstructing it.
◊Look for regurgitation on pressing over the lacrimal sac area.
◊Lacrimal syringing is done (to locate the site of obstruction).
◊Dacryocystography (which is radiological visualization of lacrimal passage after injecting radio-opaque dye).
•Examination of conjunctiva (bulbar, palpebral, and forniceal conjunctiva) for:
◊Congestion of vessels (conjunctiva or ciliary congestion).
◊Presence of follicles.
◊For its luster (it is lusterless in vitamin A deficiency).
◊Degenerative conditions (pinguecula and pterygium).
◊Any conjunctival tumor.
•Examination of cornea– Cornea is examined for:
◊Corneal size (microcornea or megalocornea)
◊Corneal curvature (normal/keratoglobus/keratoconus) by Placido’s keratoscopic disc, corneal topography, or keratometery.
◊Corneal abrasions/ulcers by staining with fluorescein (2%) or rose Bengal dye (1%).
◊Corneal transparency (look for corneal edema and corneal opacity).
◊Corneal vascularization (superficial or deep).
◊Corneal sensations (diminished in herpes, leprosy, neuroparalytic keratitis, and absolute glaucoma).
◊Corneal endothelium for keratic precipitates (KPs), and size and shape of endothelial cells by specular biomicroscope.
◊Corneal thickness by pachymeter (for accurate intraocular pressure [IOP] measurement and preoperative evaluation of refractive surgery).
•Examination of sclera: Sclera is examined for:
◊Pigmentation (in naevus of ota, which is also known as melanosis bulbi).
◊Blue discoloration (which may be associated with osteitis deformans).
◊Localized ectasia (intercalary, ciliary, equatorial or posterior).
◊Ciliary congestion (suggestive of scleritis).
◊Localized, congested nodule (suggests episcleritis).
•Examination of anterior chamber (OP6.6 for:
◊Depth of anterior chamber:
i.Deep anterior chamber is seen in aphakia, myopia, buphthalmos, keratoglobus, and posterior dislocation of lens.
ii.Shallow anterior chamber is seen in primary narrow angle glaucoma, hypermetropia, malignant glaucoma, intumescent (swollen) lens, and anterior subluxation of lens.
iii.Unequal depth (or irregular) anterior chamber is seen in adherent leucoma, tilting of lens in subluxation, and iris bombe formation due to annular synechiae in iridocyclitis.
◊Blood in anterior chambers/hyphema– seen after ocular trauma, surgery, gonococcal iridocyclitis, intraocular tumors, and blood dyscrasias.
◊Angle of anterior chamber (examined with gonioscope and slit lamp).
•Examination of the iris: Iris is examined for:
◊Color of iris (lighter/darker).
◊Pattern of iris (e.g., muddy iris in iridocyclitis).
◊Adhesions of iris (anterior or posterior synechiae).
◊Tremulousness of iris (iridodonesis): It is seen when the posterior support of iris is lost, as in aphakia or subluxation of lens.
◊Nodules on iris (Koeppe’s and Busacca nodules in granulomatous iridocyclitis/gumma of iris/tuberculoma).
◊Neovascularization of iris (rubeosis iridis): It is seen in:
–Branch retinal vein occlusion (BRVO).
–Ocular ischemic syndrome.
•Examination of pupil: Pupil is examined with reference to:
◊Number of pupil (1 or more).
◊Location of pupil (central or eccentric).
◊Size of pupil (miotic or mydriatic).
◊Shape of pupil (Table 27.2).
◊Color of pupil (Table 27.3).
Table 27.2 Conditions associated with pupillary shape
D-shape (Fig. 27.1a)
Found in iridodialysis
Found in cases of leucoma adherent
Found in acute congestive glaucoma and severe brain diseases.
Festooned pupil (on dilatation, Fig. 27.1b)
When posterior synechiae are present.