BCC / Clinical Consultation NLT

OPTHALMOLOGY

1) VISUAL LOSS / IMPAIRED

Sudden Visual Loss
- Painful - **Optic neuritis
- **GCA/AAION (HA & Jaw pain)
- *Red painful eye – Acute glaucoma / Anterior uveitis / Scleritis / (Thyroid eye disease)
- Painless - **TIA
- CRAO
- **CRVO
- VH / Retinal detachment
Gradual Visual Loss
- Red reflex (-) - Cornea opacity / ulcer
- Lens - *Cataract
- *Ectopia lentis
- VH / Retinal detachment
- Red reflex (+) - Optic nerve - **Optic atrophy
- **Papilloedema
- **Retinopathy / Maculopathy – **DM / HTN / Age-related
- **Retinitis pigmentosa
Transient Visual Loss
- **TIA
- *Migraine
- Hypoglycaemia
- Increased ICP (IIH)

2) VISUAL FIELD DEFECT

- Homonymus Hemianopia / Quadranopia – **Stroke / SOL
- Bitemporal Hemianopia – **Pituitary tumour (Acromegaly / Prolactinoma / Non-functioning)
- Tunnel Vision – Retinitis pigmentosa / Papilloedema

3) OPTHALMOPLEGIA / DIPLOPIA (OR) PTOSIS

- Neuropathy - *3rd, 4th, 6th CN palsy, (Horner’s $ for Ptosis)
- NMJ - **MG
- Myopathy - **Myotonic dystrophy / FSHD / CPEO
- Others - **Thyroid eye disease (diplopia / red painful eye / blurred vision)
- *Opthalmoplegic Migraine
- *IIH
Transient Diplopia
- *MG
- *Opthalmoplegic Migraine
- Increased ICP (IIH)

4) OTHERS
- Sjogren’s $ - Dry eye with reduced vision
- Behcet’s disease – Diplopia / red painful eye
- Red painful eye
BCC / Clinical Consultation NLT
APPROACH TO EYE PROBLEMS
- Introduction
- Look at a glance to patient for spot diagnosis
- Focus history
- C/O – visual impairment / field defect / double vision / appearance
- SOCRATES
Site*/ Onset*/ Character* (painful / painless)/ Radiation / Associations*/ Time*/
Exacerbating factors & Reliving factors / Severitiy / Impact*
- Background – Past, Drug, Family, Personal
- Focus examination
- Eye - Look – for weakness (eyelid / eyeball / pupil)
- Visual acuity – near / far / colour
- Pupillary reflex (including swinging torch test for RAPD)
- Eye ball movements (+Nystagmus)
- Visual fields
- Fundoscopy*
- Others - Face
Limbs
Relevant system
- Concern

EXAMINATION OF FUNDUS
1) Tell the patient – fixate on a distant object straight ahead; can blink but please don’t move eye & head
(Candidate – need not remove spectacles / Patient - if on thick glasses, examine with glasses in place)
2) Check and adjust the fundoscope
Use your right eye to examine the patient’s right eye and left eye to left eye
3) Check the red reflex - from at least 50 cm distance (Macleod – 10 cm)
- Red reflex is present if media (lens and vitreous) is transplant and no retinal detachment
*Cataract
*VH/RD
4) Find and look the optic disc (at nasal side / look from temporal side)
- Colour (normal – pink with pigmented temporal region) / Contour or Shape / Margin / Cup & vessels
*Optic disc swelling (blurred margin) – ON / Papilloedema / AION
*Optic atrophy (pale disc with sharp margin)
5) Follow the retinal vessels – 4 main branches, Arteries < Veins (2:3)
- Transparency of vessels / AV nipping / Focal obstruction or narrowing of arteries / Venous tortuosity
6) Look at nasal and temporal halves of the fundus
- Exudates - Hard exudates (well defined edges, increased light reflex)
- Soft exudates / Cotton-wool spots (fluffy with defined edges)
- Ring of exudates – malignant hypertension (macular star), DM (circinate)
- Haemorrhage - Dot & blot haemorrhage
- Flamed shape haemorrhage
- Pre-retinal haemorrhage / Sub-hyaloid haemorrhage
- New vessels formation
- Laser / photocoagulation scars
- Retinitis pigmentosa
*DM retinopathy – Hard exudates > Cotton wool spots / Haemorrhage (dot and blot)
New vessel formation / Lacer scars
?HTN retinopathy – Cotton wool spots > Hard exudates / Haemorrhage (flamed shape)
Papilloedema
*CRVO – Multiple haemorrhage over the whole retina / Dilated & tortuous veins / Papilloedema
?CRAO – Pale retina with cherry red spot
*Retinitis pigmentosa – Widespread scattered bone-spicule-liked black pigments esp:ly in peripheral retina
7) Look at macula area – 1 or 2 disc diameter away from & a little below the temporal margin of disc
- Ask the patient to look straight directly to the light (center of the macula – fovea)
- Haemorrhage / Exudates
- Cherry red spot
BCC / Clinical Consultation NLT
RETINITIS PIGMENTOSA

History
- Family history of blindness (can be AR, which is more severe, or AD, which is more benign)
- Decreased nocturnal vision
- Altered colour vision
- Loss of peripheral vision (Tunnel vision)
- Blurred vision.

Examination
- Widespread scattering of black pigment in a pattern resembling bone corpuscles.
- The macula is spared.
- Tunnel vision
- Cataract
Proceed as follows:
- Ptosis and Opthalmoplegia (Kearns-Sayre $)
- Deafness - Check the hearing aid (Refsum’s disease / Usher’s disease)
- Look for polydactyly in the hands and feet (Laurence–Moon–Biedl syndrome)
- Ataxia (Friedreich’s ataxia / Abetaliporoteinaemia / Refsum’s disease)

Systemic disorders associated with retinitis pigmentosa (all AR)

Kearns–Sayre syndrome, a triad of retinitis pigmentosa, progressive external ophthalmoplegia, heart block
Friedreich’s ataxia, cerebellar signs, pyramidal & posterior column signs, peripheral neuropathy
- pes cavus, ankle jerks are absent and the plantar responses are extensor.
Others - Cardiomyopathy (may cause sudden death), Optic and retinal atrophy, Diabetes mellitus
Laurence–Moon–Biedl–Bardet syndrome, which is a recessively inherited disorder characterized by
mental disability, polydactyly, syndactyly, hypogonadism, obesity and renal disease (structural
abnormalities such as calyceal cysts or calyceal clubbing and blunting).
Abetalipoproteinaemia (Bassen–Konzweig syndrome), characterized by fat malabsorption,
abetalipoproteinaemia, acanthocytosis and spinocerebellar ataxia (Ophthalmology 1984;91:991).
Refsum’s disease (phytanic acid storage disease), an autosomal recessive disorder characterized by
hypertrophic peripheral neuropathy, deafness, ichthyosis, cerebellar ataxia, raised CSF protein levels
in the absence of pleocytosis.
Usher’s disease, a recessively inherited disorder characterized by congenital, non-progressive,
sensorineural deafness

Causes
- Congenital – often autosomal recessive, 15% due to rhodopsin pigment mutation
- Acquired – Post-inflammatory

Causes of Tunnel vision

- Retinitis pigmentosa
- Papilloedema
- Advanced glaucoma
- Choriodoretinitis
- Migraine
- Hysteria
BCC / Clinical Consultation NLT

CAUSES OF OPTIC ATROPHY (PALE DISCS)

- Pressure* – tumour, glaucoma, chronic papilloedema, Paget’s disease
- Ataxia – Friedreich’s ataxia
- Leber’s hereditary OA
- Dietary – B12
Degenerative – retinitis pigmentosa
- Ischaemia – CRAO
- Syphilis and other infection e.g. CMV, toxoplasmosis
- Cyanide and other toxins e.g. alcohol, methanol, tobacco, lead
- Sclerosis* (MS)

CAUSES OF OPTIC NERVE SWELLING

1) Papilloedema
- Raised ICP – SOL, CVST, BIH
- Accelerated hypertension
- CRVO
2) Optic neuritis / Papillitis
- MS
- Severe choriodoretinitis
- B12 deficiency
- Syphilis
- CTD
- Toxins
3) AION e.g. GCA

CAUSES OF CRVO
1) Hypertension
2) Hyperglycaemia / DM
3) Hyperviscosity – Waldenstrom’s macroglobulinaemia or Myeloma, MPD
4) High intraocular pressure – Glaucoma

CAUSES OF CRAO
1) Thrombosis – Arteriosclerosis
2) Embolism – Carotid / Heart
3) GCA

STAGES OF DIABETIC RETINOPATHY

1) Background retinopathy – Routine referral to eye clinic
- Dot and Blot hemorrhages, Hard exudates
2) Pre-proliferative retinopathy – Urgent referral to opthalmologist
- Cotton wool spots, Flame hemorrhages
- Venous beading & loops and IRMA (intraretinal microvascular abnormalities)
3) Proliferative retinopathy – Urgent referral to opthalmologist
- Neovasularization
- Panretinal photocoagulation scars (treated)
4) Diabetic maculopathy – Urgent referral to opthalmologist
- Macular oedema or hard exudates within one disc space of the fovea
- Focal photocoagulation (treated)

STAGES OF HYPERTENSIVE RETINOPATHY

1) Grade 1 – Silver wiring (increased reflectance from thicken arterioles)
2) Grade 2 – + AV nipping (narrowing of veins as arterioles cross them)
3) Grade 3 – + Cotton wool spots and flame-shape hemorrhages
4) Grade 4 – Papilloedema
There may be hard exudates (macular star)
BCC / Clinical Consultation NLT