Case 1 65 year old male presents with sudden painful loss of vision. States it was preceded by nausea and vomiting.
Case 2 23 year old diabetic presents with sudden visual loss following being hit with a softball.
Case 3 57 year old man with 30 year history of DM presents with sudden onset of rapidly progressive acute visual loss.
Case 4 65 year old make presents with sudden painless loss of vision. Preceded by flashes of light and floaters.
Case 5 65 year old make presents with sudden painless loss of vision. No RAPD. Eye appears white.
Case 6 65 year old male presents with sudden painless loss of vision. No RAPD. Eye appears white. PMHX smoker, HTN and diabetes.
Case 7 77 year old make presents with sudden painless loss of vision. No RAPD. Eye appears white. Smoker, HTN (190/110).
Case 8 77 year old make presents with new distortion. No RAPD. Eye appears white.
Case 9 88 year old make presents with sudden loss of vision and says that it hurts when she chews. RAPD present. Eye appears white.
Case year old female with rapid loss of vision and decreased colour vision in the right eye. RAPD present. Eye is white.
Extraocular Causes Blepharitis/Styes Lid malpositions Ectropion Entropion 7 th Nerve Palsy Cellulitis Preseptal Orbital Conjunctival/Scleral Causes Conjunctivitis Viral Bacterial Allergic Subconjunctival hemorrhage Pinguecula/Pterygium Episcleritis/Scleritis Causes of a Red Eye
Corneal Causes Infectious keratitis Viral (HSV) Bacterial Fungal Trauma Foreign Body Abrasion Contact lens issues Intraocular Causes Hypopyon Iritis Post-operative Endophthalmitis Acute angle closure glaucoma Trauma Hyphema Causes of a Red Eye
Case 6 Episcleritis – inflammation of the episclera Scleritis – inflammation of the sclera
Case 7 Viral keratitis – HSV – viral infection of the cornea usually in a characteristic dendritic pattern
Case 8 Bacterial keratitis – bacterial infection of the cornea Fungal keratitis – fungal infection of the cornea
Case 9 Corneal Abrasion – loss of the surface epithelium of the cornea
Case 11 Hypopyon – finding on exam - variety of causes – infection, inflammation - collection of WBC in the inferior aspect of the anterior chamber
Case12 Endophthalmitis – inflammatory condition of the intraocular cavities (AC/vitreous) usually caused by infection
Basic Ocular Anatomy Extraocular Muscles - LR 6 SO 4 Lateral Rectus Laterally CN VI Medial Rectus Medially CN III Inferior Rectus Down and out CN III Inferior Oblique Up and in CN III Superior Oblique Down and in CN IV Superior Rectus Up and out CN III
Diplopia Monocular = refractive or retinal Dx: disappears when affected eye is covered but persists when unaffected eye is covered Binocular = ocular misalignment Dx: cover test reveals strabismus. Disappears if either eye is covered
Strabismus - diagnosis Right gaze Left gazePrimary gaze Upper 3 photos show comitant strabismus Lower 3 photos show incomitant strabismus
Restrictive Strabismus Orbital fracture - Hx of trauma Grave’s disease – Hx of hyperthyroidism, proptosis Orbital inflammation – red eye, proptosis, pain Orbital tumor – loss of vision, proptosis, usually no pain or redness
A 24 year old man complains of vertical diplopia worsening over the past 2-3 years. He notes he can lessen the problem by tipping his head to his left side. Cover test shows a small right hypertropia. The right eye does not depress in adduction as well as the left eye does in abduction. Review motility photos. What is the diagnosis?
Superior oblique function in various positions of gaze Primary position adductionabduction
Trochlear (4 th n.) Palsy What is the time course of the diplopia? If acute, then more likely vascular What other problems does patient have? Trauma, diabetes, BP, headache, vomiting Etiology Children – trauma, congenital Adults – trauma, vascular, (tumor)
Abducens (6 th n.) Palsy What is the time course of the diplopia? If acute, then more likely vascular What other problems does patient have? Trauma, diabetes, BP, headache, vomiting Etiology Children – trauma, post-viral, otitis, tumor Adults – vascular, trauma, tumor, ICP
Pupils Pupillary Pathways Pupillary Light Reflex CN II CN III Pupillary Size Sympathetic system - dilation Parasympathetic system – constriction Pupillary light reflex
Pupil Size Pathways
Approach to Anisocoria 1 st Question? Which pupil is the abN pupil? 2 nd Question? - What tests will I do on exam to figure that out? Pupil Size in Bright Light Pupil Size in Dim Light Pupillary Light Reaction
Horner’s Syndrome - DDx Damage to the sympathetic pathway resulting in a relatively small pupil Congenital Acquired 1 st order neuron – central lesions (hypothalamospinal pathway) Stroke, tumour, MS, cervical spinal cord lesions 2 nd order neuron - pre-ganglionic lesions Adult-Tumour apex of the lung (Pancoast) Child- Neuroblastoma 3 rd order neuron – post-ganglionic (internal carotid) Internal carotid artery dissection, cavernous sinus thrombosis, prolactinoma
Horner’s Syndrome - Ix Generally - neuroimaging CT/MRI brain and neck CTA or head/neck or Carotid doppler – carotid dissection CT chest – Pancoast tumour suspected
3 rd Nerve Palsy Parasympathetic fibres are involved when pupil unable to constrict – Pupillary fibres run along the outside of the 3 rd CN Pupil involved +/- oculomotor dysfunction – Compressive lesions are more likely » Aneurysm, tumour, uncal herniation – Motor fibres are more central in 3 rd CN Oculomotor dysfunction of CN III AND pupil spared – Intrinsic lesions are more likely » Ischemic lesions Seen in DM, GCA
3 rd Nerve Palsy - Ix Pupil involved +/- oculomotor dysfunction – Neuroimaging CTA (CT angiogram) Angiogram Oculomotor dysfunction of CN III + pupil spared – Observation » Should resolve in 8-12 weeks If not completely resolved at that point - neuroimaging
Bruckner test The simultaneous comparison of the red reflex from both eyes using ophthalmoscope (note difference in red reflex between eyes)
Amblyopia – diagnosis In verbal patient – measure acuity using the hardest test the child can do Allen picture chart (easy), tumbling E chart (harder), Snellen chart (hardest)
Amblyopia Definition Loss of visual acuity not correctable by glasses in an otherwise healthy eye (generic definition) A maldevelopment or loss of vision caused by abnormal binocular interaction or form vision deprivation during visual maturation (patho-physiologic definition) Prevalence 2 – 4 % of population Causes more visual loss and “legal” blindness (20/200 acuity) under age 45 than all other causes combined
Amblyopia – treatment Only works during “sensitive period” (roughly 0 – 6 years) Success varies inversely with age Eliminate any causes first (glasses, ptosis repair, etc.) Occlusion therapy (patching) is the gold standard
Strabismus - prevalence 2 – 4% of population (same as amblyopia, since they are so closely related)
Strabismus - diagnosis Cover test is key (gold standard)
TROPIA / PHORIA CONSTANT TROPIA: Eye turn present all of the time – Constant esotropia INTERMITTENT TROPIA: Eye turn present some of the time – Intermittent exotropia PHORIA: Eye turn present only when fusion broken – Esophoria
Strabismus - definition Misalignment of the eyes Types: Esotropia Exotropia Hyper/hypotropia ESOTROPIA HYPERTROPIA
Need to know about leukocoria – a presenting sign of retinoblastoma Ambient light reflecting off the tumor appears white or yellow-white within the pupil Strabismus is a common feature in retinoblastoma Why is leukocoria important?
Lesion to Optic Nerve
Crossing of nasal retina, which represents temporal hemifield Optic Chiasm
Lesion to Optic Chiasm
Lesions to Optic Tract upper bank of calcarine fissure Lower bank of calcarine fissure Includes visual abnormalities RAPD
Lesion of Dorsal Optic Radiation upper bank of calcarine fissure Lesions in deep parietal lobe or Occipital lobe- upper bank Calcarine fissure
Lesion of Ventral Optic Radiation (Meyer’s Loop) Lower bank of calcarine fissure Lesions in temporal lobe (classically) Occipital cortex-lower bank Calcarine fissure
5 Golden of eye trauma 1. Check vision 1st 2. Agent-of-injury is King ! c onsider FB 3. severe hemorrhage ? o pen eye 4. Stat irrigation for burns 5. Multi-trauma: ! e xamine globe 1st
Eye Trauma – timing of Rx Immediate: chemical burn * Urgent (hrs): ruptured globe, intraocular foreign body Semi-urgent (48h): lid & lacrimal repair Less urgent (1-2 weeks): orbital fractures
Focused history - Details: how, when, where.. Prior vision, eye condition Tetanus status Time of last food/drink Bedside eye exam -
Teaching point: Intraocular Foreign Body May have pain or NO pain Decreased vision or normal vision (asymptomatic!) Signs: as ruptured globe or minimal entry wound or none ! Hx: high index of suspicion (! agent-of-injury) 1 st Rx: as in ruptured globe Urgent referral for surgery NB: always check vision Consider CT, X -ray
Teaching points: Ruptured Globe CC: trauma (blunt or sharp), pain, decreased vision, ‘agent-of-injury’ Signs: conj swelling, Hb++ (3D), hyphema +/- extruded uvea, irregular pupil… 1 st Rx: protect eye with shield, NPO, bedrest, anti-nausea meds Urgent transfer to ophthalmology Caution: do not press on lids during exam ( vision –> shield –> refer )
What is your management ? Orders: – shield over Left eye – Bedrest – NPO – anti-nausea medication prn – (antibiotics..) – urgent referral to Ophthalmology
Case: Jill’s Headaches Jill, 35 y.o has had headaches, nausea, and vomiting for the past month She experiences brief episodes of dimming vision lasting seconds She also notices a pulsing noise in her head.