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الكلية كلية الطب
القسم الجراحة
المرحلة 5
أستاذ المادة اسعد جعفر عبد السادة الطائي
4/20/2011 7:56:10 PM
History taking in ophthalmology:
The conventional history taking is applicable, starting with name, age, sex, occupation, etc. ending with system review, but we are here less strict regarding each step and the order of steps.
Presenting complaints and their significance:
1) Reddness:
a- Superficial: Brick-red in colour, more intense towards the fornices, occurs in any type of conjuctival irritation e.g. :inflammation.
b- Deep (ciliary, limbal or circumcorneal): Pink with violaceous hue, more intense near the cornea, occurs in keratitis, primary angle closure glaucoma and uveitis.
c- Mixed (generalized): A combination of a and b. This is more common.
d- Circumscribed deep red patch: Subconjuctival haemorrhage.
2) Pain:
a-Severe:
i- Acute, sharp: lancinating, referred to the same side of the head and neck with or without nausea or a feeling of impending death due to acute congestive closed angle glaucoma.
ii- Dull pain: iridocyclitis, keratitis, scleritis, corneal or scleral injury or herpes zoster ophthalmicus.
b- Asthenopia: Heaviness in the lids and mild boring ocular pain due to errors of refraction and it typically follows overuse of the eyes.
c- Foreign body sensation: conjunctival or corneal foreign body,
corneal abrasion or ulcer, misdirected lash, dry-eye and keratitis (e.g. welding arc keratitis).
d- Referred pain: migraine, tension headache, sinusitis and trigeminal neuralgia.
3) Itching: a symptom of allergy.
4) Visual loss:
a- Gradual: refractive errors, cataract, primary open angle glaucoma, macular degeneration, toxic optic-neuropathies and compressive lesions of the visual pathway.
b- Sudden:
i- In one eye: central retinal artery occulsion, central retinal vein occulsion, massive vitreous haemorrhage, acute congestive closed angle glaucoma, anterior ischaemic optic neuropathy, optic neuritis, retinal detachment and hysteria.
ii- In both eyes: poisoning (methyl alcohol, arsenic, lead or ergot), severe bleeding in an anaemic patient, pre-eclamptic toxaemia and eclampsia, malignant hypertension, renal failure, cerebro-vascular accidents and hysteria.
5) Distorted vision:
a- Micropsia, macropsia and metamorphopsia: these follow macular diseases e.g : oedema or haemorrhage.
b- A curtain in front of vision: occur in retinal detachment.
c- Photopsia: occurs in posterior uvetitis, retinitis, posterior vitreous detachment, proliferative vitreo-retinopathy and aura of migraine.
6) Black spots (floaters): vitreous haemorrhage, vitreous opacities, posterior vitreous detachment or retinal detachment.
7) Haloes: occurs in corneal oedema (e.g due to acute congestive angle-closure glaucoma), lens opacities or due to thick secretions or eye ointment on the cornea.
8) Diplopia: may be vertical or horizontal crossed or uncrossed.
a- Uniocular: incipient cataract, subluxation of the lens, keratoconus or iridodialysis.
b- Binocular: extra ocular muscle palsy, orbital tumour (due to severe uniocular proptosis) or blow-out fracture of the orbit.
9) Visual disturbances:
a- Hemianopia: half field blindness.
i- Uniocular: nasal, temporal or altitudinal (upper or lower).
ii- Binocular: homonymous (right or left) or heteronymous (bitemporal or similar in shape) or incongruous.
b- Amaurosis fugax: temporary complete loss of vision due to transient ischaemic attacks.
c- Night blindness (nyctalopia):
i-Reversible: vitamin A deficiency.
ii-Irreversible: hereditary retinal degeneration e.g : retinitis pigmentosa.
d- Coloured vision: drug side effect.
e- Word-blindness: inability to read written or typed words (congenital, affects 0.1% of primary school children), the cause is a defect in the association areas of the brain.
f- Visual hallucinations:
i- Formed: temporal lobe lesion.
ii- Unformed: occipital lobe lesion.
10) Altered normal secretion:
a- Dry eye:
i- Xerophthalmia: reduced mucus secretion.
ii- Kerato conjunctivitis sicca: reduced aqueous secretion.
b- Watery eye:
i- Lacrimation: overproduction (irritation), crocodile tears.
ii- Epiphora: lacrimal drainage obstruction.
11) Abnormal secretion:
a- Serous: viral conjunctivitis.
b- Mucus: allergy, parasitic infestation, kerato conjunctivitis sicca.
c- Blood: severe viral or bacterial conjunctivitis.
d- Pus: making the lids stick together, occurs mainly in bacterial conjunctivitis.
e- Combined: e.g mucopurulent discharge in chlamydial conjunctivitis.
Examination of the eye:
Objective examinations:
These essentially demand good focal illumination provided by a good quality torch and magnification by a corneal loupe or a binocular loupe.
1) Abnormalities of appearance:
Before starting ocular examination you may observe a gross abnormality of appearance e.g: facial a symmetry due to facial palsy or abnormal head posture due to extra-ocular muscle paralysis.
2) Eye brows:
Scanty hair in myxoedema and leprosy.
3) Palpebral fissure:
In adults it is normally 28-30 mm long and 10-14 mm wide. Wide in Grave s disease and narrow in blepharospasm. It may show mongoloid or antimonogoloid slant.
4) Position of the eyes:
Check for proptosis or exophthalmos (looking over the head of the patient from behind after pulling both upper lids up open; or by the use of Hertel s exophthalmometer or a transperant ruler).
5) Ocular movement:
Tested both uniocularly (ductions) and binocularly (versions) to check for limitation of movement or extra ocular muscle paralysis.
6) Cover test:
The patient fixes a target and one eye is covered and uncovered separately at a time to test for squint.
7) Eye lids:
Look for evidence of inflammation, missing or misdirected lashes, inversion or eversion of the margin and blinking.
8) Lacrimal apparatus:
Palpebral lobe of the lacrimal gland may be examined by pulling the upper lid open and telling the patient to look down and medially, a fleshy mass will protrude from the lateral upper margin. Examine both lacrimal puncta on the lacrimal papillae at the junction of the ciliary and lacrimal portions of the margins. Look for evidence of dry eye or watery eye. Do Schirmer s test.
The lacrimal sac may show evidence of inflammation. If it is distended, it may regurgitate mucopus or frank pus when pressed on by a finger.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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