532 Cardinal symptoms Possible associated symptoms and findings Tentative diagnosis (probable underlying clinical picture) Further diagnostic work-up ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 533 ❖ ❖ 3 ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 534 Cardinal symptoms Possible associated symptoms and findings Tentative diagnosis (probable underlying clinical picture) Further diagnostic work-up Enophthalmos (eye recedes into orbit) ❖ History of trauma (signs of ocu- lar contusion). ❖ Diplopia. ❖ Eyelid swelling. ❖ Limited ocular motility in eleva- tion and depression. Fracture of the floor of the orbit. ❖ Obtain radiographs. ❖ In difficult cases, CT is indicated for precise localization of the fracture. Triad of ptosis, miosis, enophthal- mos (unilateral findings). Horner’s syndrome. Neurologic examination. ❖ Blind eye. ❖ Phthisis (shrinkage of the eye- ball). ❖ Pseudoenophthalmos (severe trauma, surgery, or retinal detachment) and chronic in- flammation (uveitis or retinitis). Ocular atrophy with shrinkage of the globe. Unequivocal diagnosis. ❖ Loss of orbital fatty tissue in advanced age (eyes recede into the orbit). ❖ Always bilateral Senile sunken eye. Unequivocal diagnosis. Exophthalmos (projecting eye) ❖ Associated hyperthyreosis (in 60% of all cases). ❖ Often in association with diplopia. ❖ Often in association with kerato- conjunctivitis sicca. Graves’ disease. ❖ Ultrasound and/or CT is indi- cated to determine whether muscles are thickened. ❖ Thyroid diagnostic studies by endocrinologist are indicated. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 535 ❖ Metamorphopsia. ❖ Retinal impression folds are vis- ible under ophthalmoscopy. Retrobulbar tumor (exophthalmos due to posterior pressure on the globe). CT scan. ❖ History of trauma. ❖ Eyelid hematoma (black eye). ❖ Eyelid swelling. Orbital bleeding. Radiographs to exclude injury of the bony structures of the orbit. ❖ Pseudoexophthalmos due to long globe. ❖ Occasionally unilateral. ❖ Difference in refraction (ani- sometropia). ❖ Poor distance vision; good near vision. Severe myopia. Refraction testing. ❖ Pain during eye motion. ❖ Diplopia. ❖ Reddening and swelling of the eyelid and conjunctiva. Ocular myositis. Ultrasound scan of the muscles. ❖ Patients are often children. ❖ Severe swelling of the eyelid and conjunctiva. ❖ Severe malaise. ❖ Affected eye is often immobile (“cemented” globe). Orbital cellulitis. Risk of blindness (optic nerve atrophy). Cavernous sinus thrombosis is a life-threatening sequela. Consult ENT specialist: Orbital cel- lulitis originates in the paranasal sinuses in 60% of all cases, and in 84% of all cases in children. Other developmental anomalies may accompany exophthalmos, which in these cases is usually bilateral. Craniosynostosis. Unequivocal diagnosis. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 536 Cardinal symptoms Possible associated symptoms and findings Tentative diagnosis (probable underlying clinical picture) Further diagnostic work-up Hypopyon ❖ Deep eye pain that hardly responds to analgesics at all. ❖ Reddening and swelling of the eyelids and conjunctiva. ❖ Acutely decreased visual acuity. ❖ Prior intraocular surgery, pene- trating injury, or corneal ulcera- tion. Acute endophthalmitis. Risk of blindness within hours. ❖ Microbiological diagnostic stud- ies. ❖ Reddening of the conjunctiva. ❖ Corneal ulcer. ❖ Eyelid swelling. ❖ Pain. Serpiginous corneal ulcer. Rapid progression of the ulcer can threaten the eye. ❖ Microbiological diagnostic stud- ies. ❖ No ocular pain. ❖ Iritis or iridocyclitis. Sterile hypopyon. ❖ Diagnostic studies for uveitis. ❖ Systemic, immunologic, and rheumatologic examinations are required. Headache ❖ Unilaterally red, hard eye. ❖ Pupil fixed and dilated. ❖ Corneal opacification. ❖ Severe pain. ❖ Frequent vomiting. Glaucoma attack. Risk of blindness. ❖ Measure intraocular pressure immediately. ❖ Sudden unilateral loss of visual acuity. ❖ Patients are usually over 60. ❖ Headache pain in temples. ❖ AION: anterior ischemic optic neuropathy due to arthritis. ❖ Giant cell arthritis in temporal arteritis. Risk of blindness. ❖ Circular or segmental swelling of the optic disk will be visible upon ophthalmoscopy. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 537 ❖ Temporal ar tery tender to palpa- tion. ❖ Pain when chewing, weight loss. ❖ Poor overall health. ❖ Myalgia. ❖ Stiff neck. ❖ Arterial biopsy and histologic examination are indicated. ❖ Determine erythrocyte sedi- mentation rate and level of C- reactive protein (precipitous drops occur in temporal arteritis). ❖ Poor vision. ❖ Eyeglasses or change of eyeglass prescription needed. ❖ Rapid fatigue (for example when reading). ❖ Burning sensation. Asthenopic symptoms. Test visual acuity. Flashes of light ❖ Often in older patients. ❖ Flashes of light and shadows seen when moving the eyes, even in the dark. ❖ Floaters. Posterior vitreous detachment. ❖ Essentially harmless age-related disorder. ❖ Examine fundus to exclude reti- nal defect. Patient sees shadows (a “wall” from below or a “curtain” from above). Retinal detachment. Risk of blindness. ❖ Ophthalmoscopy. Often without any other symp- toms. Retinal tear. Risk of retinal detachment. ❖ Ophthalmoscopy. Often encountered in patients with consumptive systemic disorders such as AIDS. Retinitis. Consult internist for diagnosis of cause. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 538 Cardinal symptoms Possible associated symptoms and findings Tentative diagnosis (probable underlying clinical picture) Further diagnostic work-up Eyelid swelling Inflammatory: ❖ Clear vesicles on the eyelids. ❖ Eyelid swelling. ❖ Inflammatory ptosis. Herpes simplex virus infection. Unequivocal diagnosis. ❖ Painful pressure point on the eyelid. ❖ Circumscribed swelling and red- dening of the eyelid. ❖ Often severe pulsating pain. ❖ Spot of yellow pus. ❖ Pseudoptosis. Hordeolum. Unequivocal diagnosis. ❖ Sting is often visible. ❖ Clear swelling. ❖ Unilateral. ❖ Itching. Insect sting. Unequivocal diagnosis. ❖ Red eye. ❖ Often few symptoms. ❖ Sticky eyelids in the morning. ❖ Purulent or watery discharge. Conjunctivitis. Microbiological diagnostic studies. ❖ Large, hard swelling and redden- ing with edema are often pres- ent. ❖ Pain. ❖ Ptosis. Eyelid abscess. Unequivocal diagnosis. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 539 ❖ Severe pain. ❖ Bleeding vesicles. ❖ Pattern of lesions follows trigeminal nerve. Herpes zoster ophthalmicus. Refer patient to dermatologist. Noninflammatory ❖ Painless, circumscribed swelling of the eyelid. ❖ No reddening. ❖ Hard palpable nodules on the eyelid. ❖ Pseudoptosis. Chalazion. Unequivocal diagnosis. ❖ Occurs in older patients (elderly skin). ❖ Limp, drooping eyelid. ❖ Drooping eyebrows. ❖ Cutis laxa senilis. ❖ Blepharochalasis. Unequivocal diagnosis. ❖ S-shaped upper eyelid. ❖ No reddening. ❖ Palpable mass. ❖ Eyelid tumor. ❖ Lacrimal gland tumor. Biopsy. No other ocular symptoms. Systemic cause (heart, kidney, or thyroid disorder). Refer patient to internist. Yellowish mobile prolapsed fat under the eyelids. Orbital fat hernia. Unequivocal diagnosis. ❖ Enophthalmos. ❖ History of trauma (ocular con- tusion). ❖ Diplopia may be present. Fracture of the floor of the orbit. ❖ Obtain radiographs. ❖ In difficult cases, CT is indicated for precise localization of the fracture. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 540 Cardinal symptoms Possible associated symptoms and findings Tentative diagnosis (probable underlying clinical picture) Further diagnostic work-up Pseudoptosis ❖ In older patients. ❖ Limp eyelid skin. ❖ Drooping eyelids. ❖ Cutis laxa senilis. ❖ Blepharochalasis. Unequivocal diagnosis. ❖ History of trauma (signs of ocu- lar contusion). ❖ Diplopia may be present. ❖ Eyelid swelling. ❖ Enophthalmos. Fracture of the floor of the orbit. ❖ Obtain radiographs. ❖ In difficult cases, CT is indicated for precise localization of the fracture. ❖ Pseudoenophthalmos. ❖ Often secondary to severe trauma, surgery, or chronic inflammation (uveitis or retinitis). ❖ Blind eye. Phthisis (shrinkage of the eyeball). Unequivocal diagnosis. Palpable, immobile swelling. Eyelid tumors. Biopsy. Ptosis Common: History of trauma or older patient. Tear in the levator palpebrae. Unequivocal diagnosis. Secondary to intraocular surgery. Elongation of the levator palpe- brae. Unequivocal diagnosis. Usually bilateral; present at birth. Congenital ptosis. Unequivocal diagnosis. Rare: Paralysis of one of all extraocular muscles. Chronic progressive external oph- thalmoplegia. Refer patient to neurologist. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 541 ❖ Eyelid swelling. ❖ Pain. ❖ Foreign-body sensation. ❖ Blepharospasm. ❖ Corneal erosion. ❖ Corneal foreign body. ❖ Subtarsal corneal foreign body. ❖ Examine cornea. ❖ Fully evert the eyelids where subtarsal foreign body is sus- pected. ❖ Apply fluorescein dye to eval- uate cornea where corneal ero - sion is suspected. Secondary to application of anti- glaucoma medications containing guanethidine. For drug side effects. Unequivocal diagnosis. Triad of ptosis, miosis, and enoph- thalmos. Horner’s syndrome. Refer patient to neurologist. Severity of ptosis can vary from day to day. Myasthenia gravis. Refer patient to neurologist. Accompanied by dilated pupil and diplopia. Oculomotor nerve palsy. Refer patient to neurologist. Pupillary dysfunction Miosis: Secondary to application of pilo- carpine. Drug-induced miosis. Unequivocal diagnosis. Secondary to use of morphine. Toxic miosis. Unequivocal diagnosis. Accompanied by ptosis and enoph- thalmos. Horner’s syndrome. Refer patient to neurologist. ❖ Accompanied by iritis or irido- cyclitis. ❖ Red eye. ❖ Pain. Reactive miosis. Unequivocal diagnosis. 19 Cardinal Symptoms Lang, Ophthalmology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. [...]... retinal damage and atrophy of the optic nerve Increased intraocular pressure, posterior subcapsular cataract Nausea, dyspnea, bradycardia Decreased intraocular pressure, miosis, decreased visual acuity, accommodation spasm Decreased intraocular pressure, cystoid Headaches, perspiration, synmacular edema cope Tachycardia, cardiac arrhythDecreased intraocular pressure, local irritation and allergic reaction... dermatogenic cataract 180, 181 diabetic cataract 179 dialysis cataract 179 galactosemic cataract 179, 185 snowflake cataract 179 tetany cataract 180 medical treatment 185 membranous cataract 285 secondary cataract 192, 193, 194, 212 – 213 Lang, Ophthalmology © 2000 Thieme All rights reserved Usage subject to terms and conditions of license C 566 Index cataract secondary cataract after intraocular surgery... Candida albicans keratitis 134 – 135 capsulorrhexis 189 carbachol 551 565 effects on pupil 224 glaucoma treatment 256 carbamazepine 557 carbonic anhydrase inhibitors 552 glaucoma treatment 255, 260, 268 carcinoma basal cell 45 – 47 conjunctival 107 lacrimal gland 66 lacrimal sac 61 squamous cell 47, 107 carteolol, glaucoma treatment 259 caruncle, lacrimal 67 cataract 12, 150, 167, 171 – 195, 434 classification... classification 171 – 172, 173 complicated cataracts 180, 181 congenital 182 – 185, 192 – 195 anterior pyramidal cataract 183 cerulean cataract 183 coronary cataract 183 from transplacental infection 185 lamellar/zonular cataract 183, 184 nuclear cataract 183, 184 polar cataract 183 definition 170 examination of 168 – 169 in systemic disease 179 – 180 cataract with myotonic dystrophy 179 – 180 dermatogenic... eyelids mia, increased blood pressure, headaches and conjunctiva, mydriasis, angle closure glaucoma Malaise, depression, metallic taste Ocular effects and side effects 552 Appendix 1 Glaucoma therapy Ocular infections with Chlamy- Conjunctival hyperemia, pain, tearing dia Rifampicin Decreased intraocular pressure, miosis, accommodation spasm, decreased visual acuity, retinal tears (rare) Mydriasis, angle... therapy Glaucoma therapy Ocular bacterial infections, especially Pseudomonas aeruginosa, Escherichia coli, Proteus species, Klebsiella pneumoniae Anti-inflammatory therapy Epinephrine Echothiophate Gentamicin Glucocorticoids Glaucoma therapy O Dipivefrin Glaucoma therapy Prophylaxis against increased intraocular pressure following laser surgery O O Indications Dorzolamide (local carbonic anhydrase... disturbances, allergic conjunctivitis O Agitated and restless states, tachycardia, insomnia Decreased visual acuity, mydriasis, angle closure glaucoma, enlarged palpebral fissures, visual hallucinations Decreased blood pressure, suppression of REM sleep phases, respiratory depression, hyperalgesia Benzodiazepines (alprazolam, diazepam, clonazepam, midazolam) Systemic side effects Ocular effects and side... O O O Haloperidol (group of butyrophenone neuroleptics) Parkinson’s disease L-dopa Epilepsy Neuralgia (trigeminal neuralgia) O O Carbamazepine Parkinson’s disease, early dyskinesia and tardive dyskinesia, liver damage Goiter, ataxia, diarrhea, tremor Mydriasis, decreased visual acuity Decreased visual acuity, nystagmus, exophthalmos (due to thyroid dysfunction) Mydriasis, angle closure glaucoma, cycloplegia,... glaucoma, decreased visual acuity, increased intraocular pressure Decreased intraocular pressure, decreased blood supply to the head of the optic nerve Decreased intraocular pressure, miosis, accommodation spasm, decreased visual acuity Decreased intraocular pressure, decreased visual acuity, dry eye Continued Ǟ Aplastic anemia (rare) Central nervous system dysfunction, tachycardia, dry mouth, nausea... blockers Clonidine Arterial hypertension Guanethidine Cardiac insufficiency Cardiac arrhythmia O O Digitalis glycosides (digoxin, digitoxin, acetyldigoxin) Arterial hypertension Coronary heart disease Cardiac insufficiency (in low doses) Ventricular arrhythmias that do not respond to treatment O Amiodarone Bradycardic arrhythmia Gastrointestinal spasms O O Atropine Indications Tachycardia, agitation, confusion . Glaucoma therapy. Decreased intraocular pressure, decreased visual acuity, dry eye. Bronchoconstriction, bradycar- dia. Carbachol Glaucoma therapy. Decreased intraocular pressure, miosis, accommodation. nausea. Chloramphenicol Severe ocular bacterial infec- tions. Local irritation, keratitis, allergic reac- tion in eyelids and conjunctiva, ker- atitis. Aplastic anemia (rare). Continued Ǟ Appendix. seconds. ❖ Darkening that may include amaurosis. Amaurosis fugax (such as in ipsi- lateral stenosis in the internal carotid ar tery). No abnormal ocular findings. ❖ Poor general health. ❖ Visual acuity improves