1. Case 1

2. SUDDEN, TOTAL LOSS, ONE EYE 70 yo F with HTN, DM lost vision in one eye over a few minutes earlier this morning. No trauma. No eye pain, or N/V Findings: –(N) External eye and EOM, red reflex –(N) Acuity on left, only hand motion right –RAPD+ –(N) Fundoscopy unaffected eye

3. Case 1 Retina pale “Cherry Red Spot” fovea Splinter hemorrhage Clinical Eye Atlas

4. Case 1 Diagnosis? Treatment? a)Massage eyeball b)Timoptic drops c)Sticking a needle in the eye Clinical Eye Atlas

5. Case 2

6. PARTIAL LOSS, ONE EYE A 60 yo M with HTN and DM complains of progressive loss of vision in one eye over the last 2 days. No other symptoms Painless uniform dulling of vision. Findings: –(N) External eye and EOM –Acuity 20/25 OD, 20/200 OS –RAPD+ –(N) Fundoscopy unaffected eye

7. Case 2 How would you manage this at 2 AM? a)Immediate ophtho consult b)Thrombolytic therapy c)Decrease the intraocular pressure d)Globe massage to dissolve clot e)None of the above Clinical Eye Atlas

8. Case 2 Unmistakable fundoscopy: “Blood and Thunder” or “Ketchup fundus” Dilated tortuous veins Flame hemorrhages Disc edema Clinical Eye Atlas

9. Case 3

10. A 50 yo M presents with a 2 day history of persistent flashing lights and floaters in one eye, as well as a tiny shadow in one corner Findings: –(N) External eye and EOM –(N) Acuity 20/20 bilaterally –(N) Visual field testing –RAPD absent –(N) Fundoscopy unaffected eye

11. Case 3 At 2 AM would you: a)Send home with GP follow-up b)Instill tropicamide and repeat exam c)Call ophthalmology immediately d)Keep the patient overnight for ocular U/S

12. Case 4

13. SUDDEN, TOTAL LOSS, ONE EYE 60 yo F with a unilateral headache for one week lost all vision in her right eye over a few minutes. No trauma, eye pain, or N/V Findings: –(N) External eye and EOM –(N) Acuity on left, only hand motion right –RAPD+ –Visual field testing normal –(N) Fundoscopy unaffected eye

14. Case 4 Clinical Eye Atlas The patient most likely has a)Papilledema b)CRAO c)CRVO d)Ischemic Optic Neuropathy (ION) e)Temporal arteritis

15. Case 4 vs Case 1 Clinical Eye Atlas Pale, swollen optic disc

16. Case 5

17. SUDDEN, PARTIAL LOSS, ONE EYE 60 yo M with migraine history complains of painful blurry vision in one eye over a few minutes. No trauma. Unlike past migraines Significant nausea, vomiting, diaphoresis Findings –Red eye –Only hand motion visual acuity one eye –Unable to examine further because of photophobia

18. Case 5 SUDDEN, PARTIAL LOSS, ONE EYE 60 yr M with migraine history complains of painful blurry vision in one eye over a few minutes. Examination reveals increasing IOP and iris pushed forward. And shallow AC.

19. Case 6

20. ACUTE, PARTIAL LOSS, ONE EYE 30 yo F with recent URI noticed pain and decreased vision in one eye over a few days. No trauma, or N/V Findings: –Red eye and painful EOM –RAPD+ –(N) Acuity –(N) Fundoscopy

22. Case 7

23. Presentation A 50-year-old male with no past ocular history presented to the Wills Eye Emergency Room with pain and foreign body sensation in his right eye. The patient works as a firefighter and had a shattered-glass injury to his eye while at work two days prior to presentation. He was found to have several small pieces of glass on his right eyelid and superficial cornea that were removed at the slit lamp. He was treated with Bacitracin/Polymixin ointment and instructed to return to the Wills Eye Cataract and Primary Eye Care clinic in one week. During his follow-up evaluation, the patient noted marked improvement of his symptoms.

24. Medical history The patient had a past medical history of hypertension and hypercholesterolemia. His medications included an angiotensin receptor blocker. There was no significant past ocular history. Family history and review of systems were noncontributory.

25. Examination At the time of the patient's follow-up presentation, uncorrected visual acuity was 20/20- in the right eye and 20/25- in the left eye. Pupils were equal, round and reactive to light without an afferent defect. Motility and confrontational visual fields were normal in both eyes. Slit- lamp examination was significant for conjunctival nodules located diffusely within the conjunctiva of both upper and lower lids. Examination of the cornea, anterior chamber and lens were within normal limits. Dilated fundus exam was within normal limits in both eyes. Anterior segment photographs obtained at the present evaluation are shown below.

26. Examination

27. Case 7

28. Case 8

29. CC: “red, itchy eyes”

30. HPI: An 11 year old M presents with red, burning, itchy eyes. The left eye first became irritated 4 days ago, while onset of right eye irritation was 3 days previously. The patient also complains of a flaky, yellow discharge and a difficulty of opening both eyes in the morning due to mattering of the eyelids. The patient denies any fevers, sore throat, sick contacts, photophobia, eye drop use, or foreign body sensation.

31. POHx: none PMHx/Birth Hx: Born at term without complications. FOHx: none All: NKDA Meds: None SHx: Lives at home w/mom and dad. No smokers or pets in home. ROS: Negative except as per HPI/PMH

32. Examination General: He is alert and appropriate. External: The eyes appear symmetric, equally red with moderate crusting & mucopurulent discharge on the lower eyelids OU. Epiphora OU. Eyes non-tender to palpation OU. Nontender R & L preauricular lymphadenopathy. Motility: Full extraocular movements. No nystagmus. Vision: 20/20 OD; 20/25 OS IOP: 17 mmHg OD, 14 mmHg OS Pupils: PERRL; no APD. No leukocoria. SLE: L/L – crusted discharge on eyelashes OU, no follicles in inferior or superior fornix OU C/S – moderate conjunctival injection OU, no chemosis K – wnl OU, no pseudomembranes noted AC – deep and quiet OU, no cell or flare Iris – wnl OU Lens – clear OU DFE: C/D 0.2, crisp disc margins, no ON hypoplasia, +foveal light reflexes, vessels wnl

33. Question 1 What is not a typical presenting symptom of conjunctivitis? A. Discharge B. Red conjunctiva C. Severe photophobia D. Burning E. Tearing

34. Question 2 A patient with a recent head cold presents with a 2 day history of a left red eye. Today the right eye is also red. The patient complaints of a lot of watery discharge, burning, and slight blurring of the vision. They deny waking up with significant discharge to the point in which their eyes are stuck shut or extreme itchiness. What is the most likely diagnosis? A. Viral B. Bacterial C. Allergic D. Not conjunctivitis – consider another diagnosis

35. Question 3 What treatment would you recommend? A. Start a topical antibiotic and contact precautions B. Admit to hospital for further work-up and treatment C. Recommend cold compresses, artificial tears for comfort, contact precautions D. Start an anti-histamine drop

36. Case 9

37. CC A 51 year-old female presents with a sudden onset of right eye pain, severe headache, blurred vision, nausea, and vomiting.

38. HISTORY The patient also reports seeing rainbow colored halos around lights. These symptoms began 2 hours ago without any inciting event. The patient was watching television when the symptoms began. There is no history of trauma, flashing lights, curtains, metamorphopsia or diplopia.

39. History Past Ocular History: Mild myopia No surgeries, laser, injection or other treatment Past Medical History: Degenerative disc disease (low back) Surgical History: None Past Family Ocular History: Father: Chronic primary angle closure glaucoma No history of macular degeneration, retinal detachment, blindness, or autoimmune disorders Social History: 30 pack year smoking history Drinks alcohol on occasion No illicit drug use Medications: Daily Multivitamin Vicodin prn (uses it about 1 day/month when back pain worsens) Allergies: NKDA

40. EXAM EXAM Visual Acuity (cc): OD: 20/70 OS: 20/20 IOP: OD: 62 OS: 11 Extraocular Movements: Intact Pupils: Right pupil mildly dilated, sluggishly responsive to light. Left normal Confrontational visual fields: Normal OU Amsler Grid: OD: Blurred throughout OS: Normal

41. Slit Lamp: Lids and Lashes: Normal OU Conjunctiva/Sclera: Injected conjunctiva OD, Normal OS Cornea: Normal OS, OD demonstrates corneal edema Anterior Chamber – Shallow anterior chamber OD, normal depth OS, Iris: Iris appears pushed forward OD, normal OS Lens: Normal OU Anterior Vitreous – Normal OU Gonioscopy: Closed angle right eye, demonstrating iris bombe (bulging of the peripheral iris). Left eye demonstrates a narrow angle, but no apparent obstruction of the trabecular meshwork. Dilated Fundus Examination: OD: Hazy view through edematous cornea, CDR (cup to disc ratio) 0.3, no AV nicking, macula normal, periphery normal with no signs of retinal breaks or detachments. OS: CDR0.3, no AV nicking, macula normal, periphery normal with no signs of retinal breaks or detachments.

42. Question 1 1. A patient presents with a sudden increase of intraocular pressure to 55 in the left eye. Gonioscopic examination demonstrates a closed angle with trabecular meshwork obstruction. Which of the following is not a likely presenting symptom in this patient: a. Nausea/vomiting b. Diplopia c. Ocular pain d. Headache e. Halos around lights

43. Question 2 2. What is the mechanism of angle closure in an episode of acute angle closure glaucoma resulting from a pupillary block? a. The lens obstructs aqueous humor flow through the pupil and creates a pressure gradient with subsequent apposition of the peripheral iris with the trabecular meshwork. b. Decreased drainage by the trabecular meshwork causes increased pressure in the anterior chamber and pushes the iris against the lens. c. A portion of vitreous humor moves anteriorly and around the lens, blocks the pupil, creates a pressure gradient that subsequently results in the iris moving forward and blocks the angle. d. Increased aqueous humor drainage through the trabecular meshwork causes a decreased pressure in the anterior chamber, causing a pressure gradient that presses the iris forward and blocks the angle.

44. Case 9

45. CC: “left eye pain and blurry vision”

46. History HPI: 65 y/o retired male engineer presents with severe left eye pain, tearing, photophobia and blurry vision since being kicked in the eye by his grandson 2 hours ago. He also reports foreign-body sensation in his left eye. He denies any flashing lights or floaters or mucous discharge from the eye. POcHx: Cataract surgery OU 3 years ago Ocular Medications: None PMH: Hypertension Medications: Hydrochlorothiazide Allergies: None FHx: Negative for blinding diseases SHx: He denies alcohol, tobacco, or illicit drug use. He lives with his wife. He has 3 children, and one grandson ROS: Otherwise negative

47. Examination VAsc 20/20 OD; 20/50 PH NI OS Pupils: ERRL, no APD EOM: Intact OU CVF: Intact OU T(p): 13 OD; 15 OS External: No periorbital edema or erythema, no ecchymosis, no lesions OU. SLE: L/L: No upper or lower lid swelling or lesions OU. Fornices evaluated and no foreign bodies noted OU. C/S: White and Quiet OD 1+ conjunctival injection, no fluorescein staining OS. K: Normal OD 2 mm by 2 mm corneal epithelial defect with fluorescein OS AC: D &Q OU I: Flat and Round OU. L: Pseudophakic OU. No evidence of lens dislocation OS. DFE: C/D: 0.2 OU Arteries/Veins/ Macula/Periphery WNL OU. No retinal detachment OS.

48. Differential Diagnosis??

49. Questions 1. What sort of symptoms would a patient who has a corneal abrasion present with? 2. What medicated drop should NEVER be given to a patient to be used at home or regularly when patients present with a corneal abrasion? Why? 3. How would you test for the presence of a corneal abrasion in the Emergency Room?

50. Case 10

51. A 67 year-old lady presented with complaints of gradual decrease in vision in both the eyes since 2 years. She was unable to carry out her daily activities and could not recognize people at some distance till they came quite close. Watching television and reading were becoming increasingly difficult for her. On examination her vision in the right eye was 6/60, while left eye had 6/36. Anterior segment examination showed normal anterior chambers with normal pupils. Lens had opacity in both the eyes, right eye more than left eye. Fundus examination showed no abnormality and Intraocular Pressure was 14 and 16.

52. Case 11

53. A 43 year – old gentleman came with problem of blurred vision in the left eye. He was a senior Executive in a software company and his work involved a lot of reading and computer work. He had been having this problem for the last 3- 4 months and it was becoming increasingly difficult for him to do his office work now. On examination he had a visual acuity of 6/6 in the right eye and 6/9 part in the left eye. Lens in the left eye showed a small central opacity while right eye was normal. Retinal examination was also normal in both the eyes.

54. Case 12

55. A 72 year – old lady had diminished vision in the right eye for 4 years. On check up her vision in the right eye was counting fingers 3 meters while left eye was 6/18. Anterior segment examination showed some clouding of the lens in both the eyes. Intraocular pressures were normal. Fundus examination right eye showed a large whitish scar in the macula while left eye showed small pale yellowish dot like lesions in and around the macula.

57. Case 13

58. One elderly lady had complaints of diminished vision in the right eye of 15 days duration. She was 69 years old and had already lost vision in the left eye 3 years back. She was not a diabetic or hypertensive. Visual acuity in the right eye was 6/24 and in the left was counting fingers 2 meters. She had Pseudophakia (Intraocular Lens) in both the eyes, having undergone cataract surgery 5 years back. Fundus examination right eye showed a whitish lesion in the macula with surrounding thickening and hemorrhage, while the left eye showed a large scar in the central area (macula). She underwent Fundus Fluorescein Angiography that showed a well-defined leak in the right eye.

60. Case 14

61. A 36 year – old mechanic was hammering on some iron rods when suddenly his right eye was hit by a flying metal piece and he felt a sharp pain in the eye followed by dimness of vision. He was brought to an Ophthalmologist who suspected an Intraocular foreign body. So he was referred to a retinal surgeon for further management. On examination his vision in the right eye was 6/12p while left eye was 6/6. Ocular examination showed mild redness of the right eye and a small white mark in the cornea with surrounding edema, which was probably the site of injury. Lens showed localized opacity (cataract) in the lower part indicating the area where the foreign body hit the lens. Fundus examination revealed a small shiny piece (foreign body) in the lower periphery, just on the retinal surface.

63. Case 15

64. A 42 – year old worker was brought with pain and loss of vision right eye. He was supervising some work in an automobile workshop when suddenly a large metal piece flew up and hit his right eye. Immediately he experienced severe pain with bleeding and complete loss of vision. On examination vision in the right eye was just perception of light while left eye was 6/6. Ocular examination showed a very soft eyeball with a large surrounding hemorrhage. The anterior chamber was full of blood and the pupil could not be seen.

65. Case 16

66. A young 32 year - old marketing officer suddenly developed floaters and a shadow in the lower part of his vision in the right eye. He immediately went to a Retinal surgeon for a check up. He had myopia and was using glasses of minus 6.5 power in the right eye and minus 4.5 in the left eye. On examination his visual acuity was 6/6 both eyes. Retinal examination with Indirect Ophthalmoscope showed a superior hole in a lattice with surrounding localized Retinal Detachment in the right eye. The central part (macula) was still attached. Left eye had weak areas in the retinal periphery (Lattice Degeneration) with a small atrophic hole in the inferior quadrant.

68. Case 17

69. A 63-year old gentleman came with marked loss of vision left eye of 1 day duration. He had developed floaters and flashes in the eye 2 days before this. He had a history of cataract surgery in the same eye 6 months back, which was uneventful with good postoperative vision. Visual acuity in the left eye was Hand movements and fundus examination showed Retinal Detachment with a large tear in horizontal meridian. There was mild vitreous hemorrhage also.

71. Case 18

72. A 56 year – old lady presented with a sudden fall in vision in the left eye of 1 day duration. She had history of Diabetes Mellitus for the last 12 years and was under treatment (oral hypoglycemic agents). But her sugar was not under control and fasting blood sugar was 180 mg/dl. On examination her vision in the right eye was 6/9 and left eye was counting fingers 2 meters. Lens showed early cataract in both eyes. Fundus right eye showed many scattered retinal hemorrhages while the left eye fundus could not be seen. Ultrasonography (B scan) left eye showed vitreous echoes corresponding to the hemorrhage and an intact retina.

74. Case 19

75. A 51-year old gentleman presented with loss of vision in the right eye of 15 days duration. He was a known diabetic for 15 years and was currently on Insulin therapy for uncontrolled diabetes. He had already undergone 3 Laser sittings in the left eye 10 months back. Six months ago he had a similar episode of sudden fall in vision in the right eye, which had slowly improved over the months but he had not gone back for a retinal examination. Now with the loss of vision of again he had come for an eye check up. On examination his vision in the right eye was perception of light and in the left eye was 6/12. Intraocular pressures were normal. Fundus examination right eye revealed vitreous hemorrhage while left eye showed Laser scars in the retinal midperiphery and no new blood vessels. Ultrasonography of the right eye showed few vitreous echoes and retina pulled up by a few membranes.

77. Case 20

78. A 64 year – old lady underwent cataract surgery in the left eye for immature senile cataract with Intraocular Lens Implantation. Preoperatively her vision in the left eye was 6/60. Postoperatively on day 1 she had vision of 6/9 in her eye and she was comfortable. The third day she experienced pain, redness of eye and blurred vision. It increased by night and the next day she went for a check up. On examination the vision in her left eye was counting fingers 1 meter. Her left eye showed mild swelling of the eyelids, with marked redness of the eye. The eye showed intense inflammatory reaction with some pus formation in the Anterior Chamber. There was a very hazy view of the fundus. Ultrasonography of the left eye showed vitreous echoes with intact retina.

80. Case 21

81. A 59 - year old shopkeeper presented with severe pain, redness, discharge and loss of vision in the left eye of 2 days duration. He had undergone cataract surgery with Intraocular lens implantation left eye one week back. Second postoperative day he developed mild irritation in the eye that increased into severe pain by 2 days. He had shown to some local doctor who prescribed him systemic antibiotics but the patient had no relief. Ocular examination showed whitish exudates in the Anterior Chamber with no view of the pupil or the fundus. Visual acuity was light perception only. Ultrasound of the left eye showed dense vitreous echoes.

82. Case 22

83. A 65- year old lady came with complaints of dimness of vision in both eyes for the last 4-6 months. She had no history of any systemic disease. Her vision in the right eye was 6/60 and left eye was 6/18. Intraocular Pressures were 12 and 14. Ocular examination showed Immature senile cataract in the left eye with very early lenticular changes in the right eye. Fundus right eye showed a Full Thickness Macular Hole while the left eye retina was normal. The patient was experiencing more problems in the right eye and wanted some remedial measures.

85. Case 23

86. A lady comes to see you to have a chat about her eyes. Over the past year, she has noticed her vision getting ‘hazy’, a bit like in the second picture shown : She now has difficulty seeing well enough to do things like read the paper; she has also stopped driving at night because she doesn’t feel safe.

88. You check her vision and it is: R 6/18+1 L 6/12-1 With a pin-hole her vision is: R 6/12-2, L 6/9+2 You check her medical record and see that the optometrist diagnosed cataracts at her last eye exam a year ago, and referred her to the ophthalmologist for cataract surgery. However, the patient did not attend the ophthalmology appointment on two occasions. You decide to talk with her about that, and discover she does not want the operation because she fears what will happen during the surgery.

89. What answers/advice do would you give this lady, when she asks you the following questions: Will they take my eye out during surgery? Will I be awake for the operation? How long will it take? Will I need to use medicine? Can I fix the cataracts with some eye drops? Will I be able to see straight after the operation?

90. Case 24

91. A 75 year old woman is seen for an annual physical examination and complains of mild difficulty in reading and seeing street signs Vision is especially worse at night, and now has trouble with her knitting PHx: HTN, T2DM diet controlled, ex- smoker O/E: VA R 6/18 and L 6/12

92. Case 24 What is the likely diagnosis?

93. Case 25

94. A 68 year old man was referred from his optometrist for visual field testing He has not reported any problems with vision, but the test report shows a reduction in peripheral vision in the RE

95. Case 25 What is your likely diagnosis? What further examination are you going to do?

96. Case 25 LERE

97. Case 26

98. A 13 year old girl is seen for physical examination at school. She admits to difficulty in reading the blackboard, but not in reading textbooks. She does not wear glasses. O/E: VA R 6/36 ph 6/6 and L 6/36 ph 6/6 What is your diagnosis?

99. Case 27

100. A 76 year old man has noted visual distortion from the RE over the past week Straight lines viewed through his right eye dipped down in the centre Round plates seem to have “edges” O/E: VA R 6/18 and L 6/6 What is the likely diagnosis? What test are you going to do?

101. Case 27