1. COMMON SIGNS AND SYMPTOMS OF EYE DISEASES

3. Components of the Ocular History
Chief complaint
What are the main problems that you are having with your eyes?
What other problems are you having with your eyes?
Why did you come (or why were you sent) here?
In what way are you hoping that you might be help?
What is it about your eyes that worries or concerns you?
What is the main problem that you would like me to address?

4. 2. Diplopia -monocular vs. binocular
1. Visual Loss-
A. transient visual loss- migraine, ischemia to eye /visual cortex
B. acute, persistent visual loss
C. chronic, progressive, visual loss- refractive, problems with ocular media or visual pathway
2. Diplopia -monocular vs. binocular

5. 3. Anisocoria
4. Metamorphopsia
5. Flashes of light -migraine, occipital epilepsy, retinal visual pathway lesion
6. Floaters- vitreous & retina
7. Eye pain- ocular & trigeminal nerve stimulation
8. Proptosis
9. Ptosis
10. Tearing -inflammation of the cornea, conjunctiva, eyelids, lids, lacrimal drainage, dry eye syndrome

6. Common Complaints
Decreased blurred central vision (distance, near or both)
Decreased peripheral vision
Altered image size (micropsia, macropsia, metamorphopsia)
Diplopia (monocular, binocular, horizontal, vertical or oblique)
Photopsias (flashes of light)

7. Iridescent vision (halos, rainbows)
Dark adaptation problems
Dyslexia (medical inability to read with normal understanding)
Color vision abnormalities
Blindness
Oscillopsia (apparent movement or shaking of images)

8. History of Present Illness
Onset (sudden or gradual); severity (improved, worsened or remained the same); Influences/Precipitating Condition; Constancy and Temporal Variation; Laterality: unilateral or bilateral
list ocular medications as well

9. Ocular Medications Medication should be recorded
including dosages, frequency and duration of use, over-the-counter drugs and home remedies
Color coded of the cap of container
Green: cholinergic or miotic drugs (pilocarpine, carbachol)
Red: anticholinergic or dilating cycloplegic (atropine, tropicamide, cyclopentolate, phenylephrine)
Yellow: Beta-adrenergic blocking agent (timoptol)
White: antibiotics, artificial tears, corticosteroids
Orange: (dorzolamide)

10. Past medical history general state of health
principal systemic illnesses
Vascular disorders commonly associated with ocular manifestations-such as diabetes and hypertension-should be asked
list the patient's systemic medications
any drug allergies should be recorded
Use of eyeglasses or contact lens
Use of ocular medications in the past
Ocular surgery
Ocular trauma

11. Systemic Medications
Use of aspirin, anticoagulant agent, antibiotics, tranquilizers, narcotics, anti-inflammatory agents, anticonvulsants, contraceptives, or vitamins

12. Allergies Medications Environmental agents resulting in:
Atopic dermatitis
Allergic asthma
Allergic rhinitis, conjunctivitis (hay fever)
Urticaria (hives)
Vernal conjunctivitis

13. Family history
strabismus, amblyopia, glaucoma, cataracts, and retinal problems, such as retinal detachment or macular degeneration.
Medical diseases such as diabetes may be relevant as well

14. COMMON OCULAR SYMPTOMS
three basic categories:
I. abnormalities of vision
II. abnormalities of ocular appearance
III. and abnormalities of ocular sensation-pain and discomfort.

15. I. ABNORMALITIES OF VISION
1. Visual Loss
due to abnormalities anywhere along the optical and neurologic visual pathway.
consider refractive (focusing) error, lid ptosis, clouding or interference from the ocular media (eg, corneal edema, cataract, or hemorrhage in the vitreous or aqueous space), and malfunction of the retina (macula), optic nerve, or intracranial visual pathway.

16. 2. Visual Aberrations Glare or haloes Visual distortion
-may result from uncorrected refractive error, scratches on spectacle lenses, excessive pupillary dilation, and hazy ocular media, such as corneal edema or cataract.
Visual distortion
(apart from blurring) may be manifested as an irregular pattern of dimness, wavy or jagged lines, and image magnification or minification.
Flashing or flickering
lights may indicate retinal traction (if instantaneous) or migrainous scintillations that last for several seconds or minutes.

17. Double vision (monocular or binocular) Monocular diplopia
Floating spots
may represent normal vitreous strands due to vitreous "syneresis" or separation or the pathologic presence of pigment, blood, or inflammatory cells.
Double vision (monocular or binocular)
(ie, disappears if one eye is covered).
Monocular diplopia
Persists when one eye is covered
It is caused by an optical aberration (cataract, uncorrected refractive error, presbyopia, keratopathy).
Binocular diplopia
disappears when either eye is covered.
It results from misalignment of the eyes, and may be caused by:
a central nervous system lesion
an ocular motor nerve lesion
a neuromuscular junction lesion
extraocular muscle lesion

18. SYMPTOMS Early Difficulty reading, driving, etc
Straight lines may be crooked
Advanced: central blind spot
Peripheral vision remains
Independent living skills
Disturbance of vision first
Progressing to diminution
Cataract size & location determine impairment

19. II. Abnormal appearances
Ptosis (drooping of the eyelid)
Proptosis (protrusion of the eyes)
Enophthalmos (opposite of proptosis)
Blepharitis
Misalignment of the eyes
Redness, other discolorations, opacities and masses
Anisocoria (inequality of the pupils)

20. III. Ocular pain or discomfort
Foreign body sensation
Ciliary deep pain
Photophobia (pain that is present upon exposure to light)
Headache
Burning
Dryness
Itching
Asthenopia (eyestrain)

21. Abnormal ocular secretions
Lacrimation
Epiphora (actual spilling of tears)
Dryness
Discharge

22. VISUAL ACUITY
numerator - testing distance from the eye to the chart being used (20 feet or 6 meters);
denominator - distance to which the subject with an impaired vision can read the same figure.

23. Testing Distance Visual Acuity
1. Ask the patient to stand or to sit at a designated testing distance, 20 feet from a well-illuminated wall chart.
Occlude the left eye.
Ask the patient to read aloud each letter, number or picture from left to right.
Note the corresponding acuity measurement shown at that line of the chart. Record the VA of each eye separately with correction and without correction.
Repeat steps 1-4 for the left eye, with the right eye covered.
20 ft

24. Pinhole acuity test
The pinhole admits only central rays of light which do not require refraction by the cornea or lens.
A single pinhole no more than 2.4 mm in diameter should be used.

25. Testing Pinhole Visual Acuity
Position the patient and occlude the eye not being tested, as done for the distance acuity test.
Ask the patient to hold the pinhole occluder in front of the eye that is to be tested.
Instruct the patient to look at the distance chart through the single pinhole or through any one of the multiple pinholes.
Instruct the patient to use small hand or eye movements to align the pinhole to resolve the sharpest image on the chart.
Ask the patient to begin to read the line with the smallest letters that are legible as determined on the previous vision test without the use of the pinhole.
Record the Snellen acuity obtained and precede or follow it with the abbreviation PH.

27. Jaeger chart Used to express near visual acuity.
The test is usually performed at 16 in or 40 cm.

28. Testing Near Visual Acuity
Instruct the patient to hold the test card at the distance specified on the card (16 in or 40 cm).
Ask the patient to occlude the left eye.
Ask the patient to read each word on the line of smallest character that is legible in the card.
Record the VA for each eye separately.
Repeat the procedure with the right eye occluded.

29. Testing Poor Vision Count fingers (CF) Hand moving (HM)
Light perception (LP)
If cannot perceive light: totally blind (NLP or no light perception)

30. Testing Peripheral Vision
Confrontation test
Simultaneous confrontation test

31. Test for Pupils Direct response to light Consensual constriction
Swinging penlight test for Marcus Gunn Pupil or relative afferant pupillary defect

32. The “swinging flashlight test” assesses CN II, CN III (parasympathetic innervation of the sphincter pupillae muscle), and sympathetic innervation of the dilator pupillae muscle.

33. Test for Ocular motility

34. Testing Alignment
Cover test: gaze at a distant object. Cover one eye

35. Direct Ophthalmoscopy
Fundus examination
Anterior segment examination
Red reflex examination

37. Mydriatic (dilating) Drops
2.5% phenylephrine
0.5%-1% tropicamide

38. Specialized Ophthalmologic Examinations
Perimetry
systematic measurement of visual field function (the total area where objects can be seen in the peripheral vision while the eye is focused on a central point

39. Specialized Ophthalmologic Examinations
Amsler Grid
tool for monitoring central visual field.
to detect early and sometimes subtle visual changes in a variety of macular diseases such as age-related macular degeneration and diabetic macular edema

40. Metamorphopsia: macular edema, submacular fluid

41. Color Vision Testing

42. Thank you