EYE DIAGNOSIS MADE EASY

BY

KEM3BIANS BATCH 23
 EYE DIAGNOSIS

I will try to cover some IMP points helpful in making a diagnosis. They are mostly the ones used in Past Ppr
SEQS.
But the only way to really get them is to see past pprs yourself. No amount of reading this is going to really help
you without practice.

The easiest way to prepare is to:

• Do the Eyelid and Lacrimal Topics as there is 1 SEQ from each i.e. 2 SEQS done
• Next do Lens, Glaucoma and Refraction i.e. 3 SEQS. These are usually clear and easy scenarios plus
they make up about 80% of your viva
• 1 SEQ from uveal tract (usually Ant uveitis) appears nearly every year.
• And 1 SEQ from Optic Nerve is a must. It’s also easy because most of the time there are only 2
diagnoses so FREE marks!

That’s 7 SEQs until now i.e. 70% of the paper.

The remaining SEQS are:

• 1 from metabolic disorders. It is usually going to be thyroid eye disease, diabetic retinopathy or CN
palsy
• 1 from vitreo-retina
• 1 from conjunctiva, cornea, sclera combined (ugggghhhhhhhhhh)

And that makes up the complete 10.

Tip:
If you can’t decide on a diagnosis in paper for some really confusing SEQ. Count up the Qs you have already
done acc. to the TOS to figure out which chapter question is remaining.
For Example: If you have solved everything else and you haven’t seen a Q for glaucoma yet, then the remaining
Q is probably glaucoma (sometimes appears as a simple painful red eye Q).
 EYELID

The 1st SEQ is usually from this chapter.

• Chalazion= Painless gradually increasing swelling usually on upper eyelid

Marginal Chalazion= red nodule on lid margin

• Hordeolum
Painful tender swollen eyelid
H.Internum= Pus on pressure. Yellow spot on conjunctiva
H.Externum= Pus points towards lid margin with lash in centre

• Blepharitis
Ulcerative= Gluing of lashes with yellow crust removal leads to bleeding ulcer
Squamous= Waxy dandruff like desquamation no ulcer on scale removal
Posterior=white frothy secretion with burning sensation

• Ectropion t
The main P/C = Epiphora

LACRIMAL SYSTEM

Usually there is a 50% chance the SEQ will be about Dacrocystitis with a 100% chance it will be confusing
whether it’s acute or chronic.
The only reliable marker in the solved past papers is acute if its painful or chronic if there is no pain or if its
prolonged and then becomes painful suddenly you can say acute on chronic but i am not sure about this.
The eye dept. just can’t make good/clear SEQs.

Congentinal NLDO= Bilateral Watering with Regurgitation Test positive (remember wait for spontaneous
recanalization)
Acq NDLO= Idopathic females tearing with recurrent attacks of Dacrocystitis/conjunctivitis
Acute Dacrocystitis= PAINFUL swelling at medial canthus with epiphora. Regurgitation Test not done
Chronic Dacrocystitis= Constant watering with swelling (usually not painful).
Dry Eye= Pain worsens with blinking. Examination shows Corneal filaments, mucous debris, punctuate
epithelial erosion.
 CATARACT

The scenarios are usually pretty clear.

Senile Cataract= 50 years
Cuneiform Type = VA loss with Glare Halos
Cupuliform Type= Glare with Day blindness and No halos
Nuclear Type= Black Cataract, Cloudiness and myopic shift and colour shift

Some Really IMP ones:

After Cataract= Painless vision loss after cataract surgery
Cataract patient develops painful red eye= Phacomorphic Glaucoma
Better at night worse in day= Senile posterior sub capsular (or central nuclear) cataract

GLAUCOMA

Congenital= In Boys bilateral, Pseudoproptosis with haziness and BLUE SCLERA and megalocornea.

POAG= Usually in myopes, most common type= Painless slow progressive vision loss, IOP raised, open angle

PACG=In hypermetropes
• Latent= No symptoms, IOP normal, Ant Chamber depth less than normal.
• Sub Acute= Episodes of blurry vision with halos and pain, IOP 40 45 but returns to normal in 1 2 hr.
• Acute (IMP)= Sudden IOP rise to 70 with severe vision loss Red eye, white patches on iris, Pupil mid
dialated and oval.
• Chronic= IOP rises slowly with synechie formation.
• Absolute= Painful or painless blind eye with optic atrophy.

Not IMP but if someone asks:

Normotensive Type = Women 60 yrs bilateral splinter hemorrhages assoc. with sys hypotension

REFRACTION
The diagnosis is easy enough but don’t confuse the plus/minus lens.

Tip:
• Minus(concave) is for myopes
• Plus(convex) is for hypermetropes
 UVEA

Usually there is a 99% chance there will be a SEQ about Anterior uveitis in the Ppr.

Ant Uveitis= Sudden onset Pain worsens at night

Shows circumcorneal congestion and Keratic precipitates with anterior aqueous flare and aqueous cells
Pupil is Constricted and sluggish (compare Glaucoma with mid dilated oval pupil)

The rest of the types are unimp.

Intermdiate Uveitis= Bilateral insidious with floaters, snow balls and banking
Post Uveitis= Gradual painless vision loss with Floaters(Black Spots), Positive Scotoma, vision abnormalities

IMP ones again:

Endophthalmitis (Past Ppr Q) vs Panopthalmitis = see flowchart page 6

VITREOUS
Sudden painless vision loss with black floaters

RETINA
Diabetic Retinopathy:
Remember Definition and risk factors
Diff btw NPDR and PDR is the appearance of new blood vessels IMP
Focus on Diff treatments for diff types
The scenarios are usually pretty clear

Types of emboli in CRAO with treatment is a Past Ppr Q

Retinal Detachment:
Flashes, floaters, curtain effect, sudden painless loss
Rhegmatogenous= In MYOPES or due to trauma
Tractional= In proliferative Diabetic retinopathy
Exudative= In inflammation and tumors, shows shifting fluid

Retinitis pigmentosa:
Shows RING SCOTOMA, tubular vision and night blindness
Disc shows= waxy appearance attenuated vessel bone corpuscles

Retinoblastoma:
Is a tumor of the sensory retina
Presents as Leukocoria with Convergent squint
Tip:
White Reflex (leukocoria) in kids less than 3 think retinoblastoma (99% chance) first.
 OPTIC NERVE
This is usually the first Q on the backside of the paper (99% of the time) and Yes the Eye dept. is too lazy to
change its position (and Yes i was bored enough to notice it).

There are usually only 2 diagnoses

If there is bilateral disc swelling with:
 Headache vomiting worsens on sneezing coughing = Papilloedema
 RAPD positive, colour vision decreased, Visual acuity decreased + pain= Papillitis

On the off chance there are papillitis symptoms but with normal disc in young adult (may have multiple
sclerosis) its retrobulbar optic neuritis (PAST PPR Q)

And this one is not IMP but:

Optic Neuritis= Painful sudden with central scotoma. Optic nerve function decreased with phosphenes

For an easy concept:

Lid Edema + Red Eye +

Pain

Extraocular Muscle
No Restriction
Movement Restriction

ORBITAL CELLULITIS PANOPTHALMITIS ENDOPTHALMITIS

RAPD +ve Hazy cornea NO RESTRICTION PRESEPTAL CELLULITIS
Hypopyon No RAPD/Colour
Colour Vision Decreased Chemosis
Hazy Cornea vision/VA/Muscle
PROPTOSIS Hypopyon problem
Lacrimation Photophobia
May Show Disc Edema IOP Raised

and
 Defect In Colour Vision With
RAPD +Ve
(Optic Nerve Problem)

ORBITAL CELLULITIS Papiloedema vs Papillitis

Lid Edema Present Lid Edema absent

METABOLIC DISORDERS
There is usually one about Thyroid eye disease which is pretty clear (protruding eyes frightened look)
Or about Diabetic Retinopathy
But sometimes they ask from paralytic squint because it can be caused by Diabetes and HTN.

3rd Nerve Palsy= Complete ptosis, Pupil dilated with poor response, Eye down and out but abduction normal
(See Pupil sparing lesions)
4th Nerve Palsy= Vertical diplopia with opposite head tilt
6th Nerve Palsy= Horizontal Diplopia with same side head tilt
There is only one seq from these 3 chapters of conjunctiva, cornea and sclera and most of you are going to skip
them (I know)

CONJUNCTIVA
Lacrimation Stinging Grittiness Burning

• Bacterial:
Mucopurulent= Acute, eyelid matted by discharge.
Purulent= Hyper acute, thick profuse creamy pus, chemosis and LYMPHADENOPATHY
Membranous= Acute serous discharge, true whitish membrane and LYMPHADENOPATHY

• Viral:
Acute watery discharge with red eye
Diagnosis: Immunofluorescence, PCR Ig level
No effective treatment No antiviral only Cold water soothes

The first 3 types are not that IMP

EKC= Acute follicular type with punctuate epithelial keratitis pseudomembrane lymphadenopathy (Adenovirus
8 19 37)
PCF= Acute follicular type + fever and pharyngitis (Adenovirus 3 4 7)
Picornavirus Conjunctivitis= Bilateral watery red eye.

IMP ones now

HSV= Follicular type, vesicles on lid margins, pseudomembrane, punctuate keratitis forms opacities which
forms multiple DENDRITES.
Molluscum Conjunctivitis= UNILATERAL CHRONIC red eye MUCOID discharge pale waxy umblicated
nodule

• Chlamydia (IMP):
Trachoma (see definition from book i am too lazy to type it here)
Disease Progression: Follicles rupture with scarring and corneal pannus
Remember Arlts line and Herbert Pits
And FISTO grading

• Ophthalmia Neonatorum:
Diff btw its types are
• Chemical= Few hrs self limiting
• Gonococcal(most likely to be asked)= Hyperacute 2-4 days purulent with pseudomembrane
• Chlamydia= Subacute 1-3 weeks mucopurulent with pannus and scarring
• Other bacteria= Subacute mucopurulent
• Viral= by HSV2 subacute
 • Allergic:
Itching redness

The most likely to be asked is vernal keratoconjunctivitis(VKC)

VKC= Type 1and 4 reaction to exogenous allergen.
IMP point: Bilateral Recurrent usually male 5 to 15.
Types are:
1 Palpebral(large papilla with ropy mucoid secretion)
2 Limbal(gelatinous papilla with transtas dots)
3 Mixed

Tip:
If they ask inflammed eye with large/giant/cauliflower/cobblestone papilla its VKC.
See treatment for VKC. You can write it in any allergic scenario.

Phlyctenular KC=Type 4 reaction to endogenous allergen.

Usually in 1st two decades of life.
A phlyctenule follows a 10 day course.

• Autoimmmune (Not IMP):

Pemphigoid= Type 2 reaction with Blistering ulcer and scarring usually in female above 60.
SJS= In females, Type 4 reaction with hemorrhagic crusting in eye and target skin lesion.

• Pterygium (IMP)
Presents as triangular growth in intrapalpebral region with astigmatism and mechanical obstruction may show
Stocker iron deposition line.
IMP Complications are pyogenic granuloma and recurrence (Past PPR Q)

CORNEA

• Bacterial = Hazy cornea with hypopyon

• Fungal= History of AGRICULTURAL TRAUMA/TOPICAL STEROIDS =grey white (filamentous)
or yellow white suppurative(candidal)
• Acanthamoeba= CONTACT LENS = pseudodendrites with ring abcess
• HSV= Usually unilateral with dendrite and geographical ulcers

Keratoconus= Bilateral with progressive vision loss aNd munson sign, oil droplet reflex, scissor reflex,
And the one for viva:
Mooren= Autoimmune limbal vasculitis unilateral in old and Bilateral in young

Tip:
Ulcer Q will probably be like eye shows defect under Flourescien Dye = 100% Ulcer.
Remember the treatment for Bacterial type and copy paste with some common sense
 SCLERA
Episcleritis= SUDDEN benign self-limiting movable blanchable female 20 50
Scleritis= GRADUAL immune complex vasculitis pain and visual loss non movable/blanchable.

ORBIT
Preseptal Cellulitis= Inflammed swollen red painful eyelid with No other visual signs
Orbital Cellulitis= Rapid painful swollen eye with proptosis, decreased muscle mobility, disc edema and visual
loss/Colour vision/RAPD.
For diff btw them (see flowchart page 6)

Cavernous Thrombosis=Usually Unilateral with proptosis, periorbital edema, CN 5 and 6 involvement and
oedema over mastoid

OCULAR INJURIES

Just some IMP points for MCQs:

Slit lamp examination is best for corneal foreign body

Contusion produces black eye
Trauma= Subcapsular cataract
Commotio retina is edema of the retina
Dont do MRI in metallic foreign body
Blunt trauma is the most common cause of Hyphaema

Read Hyphaema and Acid/Alkali treatments