eye cases: how?

DR. PRANAV BHAGWATDR. JIJITH C.R.

HISTORY TAKING

– Allow patient to tell story.

Decreased vision

Ask for

• Onset

• Duration

• Uni / Bilateral

• Distant or near vision

• Whether the patient wears glasses

• Diurnal variation

Sudden unilateral loss of vision

• Acute congestive glaucoma• Acute optic neuritis• Acute iridocyclitis• Retinal detachment• Central retinal artery occlusion• Spasm of retinal artery• Vitreous haemorrhage• Injuries

Sudden bilateral loss of vision

• Acute methanol toxicity

• Hysteria

Reduced vision in the morning, improved in afternoon

• Intermittent corneal edema

Gradual onset loss of vision

• Cataract• Refractory errors• Retinopathy-DM, HT• Retinal degenerations

and RP• Chronic iridocyclitis• Chronic simple

glaucoma

• Keratitis• K opacities• Chorio retinitis• Chronic optic neuritis• MS• Drug toxicity

Pain in the eye

• Type

• Onset

• Duration

• Diurnal variation

• Associated complaints e.g., nausea, vomiting, DV

Severe eye pain

• Adhimantha

• K abrasions and ulcers

• Acute iridocyclitis

• Panopthalmitis

• Acute glaucoma

• Scleritis

• Episcleritis

Dull Aching pain

• Cases with eye strain

Mild eye pain

• Corneal FB

• Conjunctival FB

• Conjunctivitis

Pain around the eye

• Pathology of the lid and lacrimal apparatus (eg: stye)

Redness of the eye

Normal eye lid with normal corrected visual acuity

• Conjunctivitis

• Keratitis

• Corneal ulcer

• Arjuna

• Episcleritis

Abnormal eye lid with normal corrected visual acuity

• Ectropion

• Entropion

• Stye

• Blepharitis

Reduced corrected visual acuity without diplopia

• Iritis

• ACG

• K foreign body

• K ulcer

Reduced corrected visual acuity with diplopia

• Carvernos sinus thrombosis

• Orbital cellulitis

• Caratico carvernos fistula

Common causes –red eye.

Photophobia

• Acute infective or inflammatory lesion of the anterior segment

• Recently operated eyes

Watering of the eyes

1)Excessive lacrimation• Keratitis• Uveitis• Glaucoma

2) Epiphora• Mechanical obstruction to drainage- stricture,

punctal stenosis & chronic dacryocistitis• Defective orbicularis action

Discharge

• Watery-Mild bacterial infection

• Serous -viral

• Mucoid -mild conjunctivitis

• Mucopurulent & purulent- acute pyogenic infection of anterior segment

• Serosanguinous- opthalmia neonatrum

Itching

• Allergic disoders- phlycten

• Episcleritis

• Spring catarrh

• Allergic blepharo conjunctivitis

Netra daaha

• Pittotklishta

• Pittaja abhishyanda

• Pitta vidagdha drishti.

Foreign body sensation

• Presence of FB

• Distorted eye lashes- trichiasis, entropion

• Conjunctival concretion, calcification

• Contact lenses

Black spots in front of eyes

• 1) Stationary

K scars, lens opacity

• 2) Mobile- Vitreous opacities

Headache

• Refractive errors

• Improperly corrected refractive errors

• Zoster

Haloes around light

• 1) Early ACG

• 2) Acute mucopurulent conjunctivitis

• 3) Early stages of cataract

Photopsiae

• Irritative lesions of retina

• Impending RD

Diplopia

• 1) Unioccular- high K astigmatism, subluxated or dislocated lens

• 2) Binocular- Squint

Nyctalopia

• Vitamin A deficiency

• Retinitis pigmentosa

• Pathological myopia

• Glaucoma

Occupation

• Welders

• Black smiths- foreign body in the eye

• Farmers- fungal keratitis

Medication

• 1) Gentamicin, miotics, Atropin- follicular response

• 2) Topical anasthetics for long time- severe corneal reactions

• 3) Topical and systemic steroids- K disease, cataract, glaucoma

• 4) Thiomersal- allergic conjunctivitis, epithelial Keratitis

• 5) Benzalkonium- toxic papillary reaction

Past history

• Systemic diseases- diabetis mellitus

• Arjuna-HT

• Iritis- ankylosing spondylitis

History of previous ocular disease

• Childhood squint- lazy eye

• Blunt injury- traumatic mydriasis ( could be confused with partial third nerve palsy)

Family history

• Chronic glaucoma- the incidence nearly 5 times greater in siblings and children of affected patients

Examination of the function of eye

Visual acuity

• Snellen’s chart- 6 mtrs

• Wear his distant corretion

• One eye at a time

• 6/60 - 6/6

• CF at 1 meter

• Hand movements

• PLPR

• Jaeger’s test type

• N5 to N48

Visual field

• 1) Peripheral field- confrontation or perimeter

• 2) Central field by scotometery

Colour vision

• Ishiahara chart

Ocular and periocular examination

• 1) Head posture-

Paralytic squint.

Face

• Look for

• Asymmetry

• Signs of paralysis

• Obvious skin changes

Orbit

• Inspection and palpation

Eye brows

• Look for loss of hair- lepromatous leprosy, myxoedema

• Depigmentation

Eye lid

• 1) Position of the lid margin in relation to cornea- drooping of lids

• 2) Thickness of the lid• 3) Swelling

a) Localised eg) Stye, chalazion

b) Generalised- Oedema,ecchymosis

Pakshma mandal

• Trichiasis- misdirection of lashes

• Distichiasis- double row

• Madarosis- scantiness

• Matting- conjunctivitis

Shuklamandal (conjunctiva & sclera)

• 1) Bulbar conjunctiva

a) congestion- ciliary/conjunctival

b) Chemosis-

c) Subconjunctival haemorrhage

d) Pigmentation

e) Nodule

Upper tarsal conjunctiva

• Congestion

• Alteration of normal vertical vascular pattern

• Follicle/papilla

• Scarring

• Membrane formation

• Granuloma

• Foreign body

Lower tarsal conjunctiva

• As above + any sign of symblepheron

Staining

• 2% fluorescein- raw area- green

• 1% rose bengal- conjunctiva- pinkish red

Sclera

• Colour change • Pigmentation• Protrusion of uveal

tissue• Congestion

• Nodule formation

Krishnamndal (cornea & iris)

• Cornea

• 1) Size- normal (12 to 13 mm)

• 2) Curvature-conical / globular / flat

• Surface- examine by window reflex / placido disc / slit lamp

• Irregular surface- corneal ulcer, scarring

• Depression / corneal facets

• Elevation- epithelial bulla

• Opacity

• 1) density- nebula / macula / leucoma

• 2) Situation and extent in relation to pupil

• 3) Iris adhesion

• Pannus (sirashuklam)-

• Keratic precipitates

• Corneal sensationsDiminished sensation- • Herpes• 5th nerve paralysis• ACG and absolute glaucoma• Leprosy• Prolonged use of contact lens• Post surgery• Local anaesthesia

• Corneal stains

Iris

• 1) Iris pattern

• 2) Colour

• 3) Vessels- visible = patho.

• 4) Atropic patches = end stage of glaucoma

Defect in the iris

• Iridodonesis- aphakia / buphthalmos

• Iridodyalisis

• Anterior synechia

• Anterior chamber

Depth and content

Pupil

• Size- (3 to 4mm)

• Shape

• Position

• Pupillary margin

• Pupillary aperture

• Pupil reaction

Lens

• Colour

• Opacity

• Position

Pakshmavarthmagathasanthi

• Entropion

• Ectropion

• Tylosis

• Milphosis

Kaneenika sandhi

• Lacrimal puncta- eversion / stenosis / absence

• Skin around it

Shuklakrishnagatha santhi

• Nodule• Congestion

Tonometrytonopen Shiotz tonometer.

Fundoscopy

Ocular coherence tomography

• Thank you!