Manual of Ophthalmic Diagnosis E Ahmed
Chapter Notes

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Differential Diagnosis of Ocular Symptoms and SignsChapter 1

Ocular Symptoms
Acute Red Eye
  1. Bilateral, painless with good visual acuity
    1. Bacterial conjunctivitis
    2. Viral conjunctivitis
    3. Allergic conjunctivitis.
  2. Bilateral, painful with or without impaired vision
    1. Viral keratoconjunctivitis
    2. Chlamydial keratoconjunctivitis.
  3. Unilateral, painless with normal visual acuity
    1. Conjunctivitis—Sometimes unilateral
    2. Inflamed pinguecula
    3. Progressive pterygium
    4. Episcleritis—Often irritation rather than pain present.
  4. Unilateral, painful with normal visual acuity
    1. Marginal corneal ulcer
    2. Scleritis
    3. Early stage of anterior uveitis.
  5. Unilateral, painful with decreased visual acuity
    1. Herpetic keratitis
    2. Severe acute anterior uveitis
    3. Acute closed-angle glaucoma
    4. Secondary glaucoma
    5. Corneal ulcer
    6. Zoster keratitis
    7. Chemical or mechanical injury.
See under Diseases of the Conjunctiva, P. 88.
Gradual Visual Loss in Senile Age-group
  1. Is the affection uniocular or binocular?
  2. What is the duration?
  3. Is the visual defect central or global?
  4. Is there any family history of glaucoma?
  5. Is the patient suffering from diabetes, hypertension or other systemic disease?
  6. What is the nature of treatment done so far?
  1. Distant and near vision (Figs 1.1 and 1.2)
  2. Vision with pinhole (Fig. 1.3). When defective vision improves with pinhole it indicates that the vision will improve with lenses
  3. Rough assessment of visual field by confrontation test
  4. Examination of the anterior ocular segment
  5. Measurement of intraocular pressure (IOP)
  6. Ophthalmoscopy after pupil dilatation
  7. Occasionally testing of color vision.
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Fig. 1.1: Snellen distant test types.
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Fig. 1.2: Near vision test types.
  1. Major
    1. Cataract
    2. Refractive error
    3. Primary open-angle glaucoma
    4. Age-related macular degeneration
    5. Diabetic maculopathy.
  2. Rare
    1. Optic atrophy
    2. Optic neuropathy
    3. Vitreous opacities.
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Fig. 1.3: Pinhole.
Acute Painless Visual Loss
Visual loss lasts longer than 24 hours.
  1. Unilateral
    1. Central retinal artery obstruction
    2. Central retinal vein thrombosis
    3. Central serous retinopathy
    4. Retinal detachment
    5. Vitreous hemorrhage
    6. Ischemic optic neuropathy
    7. Choroiditis.
  2. Bilateral
    1. Malignant hypertension causing macular edema
    2. Long-standing papilledema
    3. Chiasmal and retrochiasmal lesions.
Investigations for Acute Painless Visual Loss
  1. Is it in one eye?
  2. Are both eyes affected?
  3. Are the symptoms constant or intermittent?
  4. Is the condition static, improving or worsening?
  5. Is the visual loss mild or severe?
  6. Is the patient hypertensive or diabetic?
  1. Check-up of visual acuity
  2. If feasible, check-up of visual field
  3. Pupil reactions before dilatation of the pupils
  4. Direct/indirect ophthalmoscopy
  5. Color fundus photography
  6. Fundus fluorescein angiography (FFA)
  7. Ultrasonography (USG).
Acute Painful Visual Loss
  1. Acute closed-angle glaucoma
  2. Optic neuritis
  3. Uveitis
  4. Endophthalmitis
  5. Acute keratoconus-corneal hydrops.
Transient Visual Loss (Amaurosis Fugax)
  • There is monocular or binocular abrupt loss of vision
  • Vision returns to normal usually within one hour.
  1. Transient ischemic attack
  2. Papilledema
  3. Migraine
  4. Ischemic optic neuropathy
  5. Impending central retinal vein thrombosis
  6. Postural hypotension
  7. Severe anemia
  8. Giant cell arteritis
  9. Cervical carotid stenosis.
This is based on:
  1. Clinical characteristics
  2. BP, ECG and echocardiogram
  3. Carotid ultrasound
  4. CT angiography
  5. MRI angiography
  6. Blood tests like total count, serum protein electrophoresis, prothrombin time, etc.
Ocular Pain
  1. Conjunctivitis
  2. Episcleritis
  3. Scleritis
  4. Keratitis
  5. Acute glaucoma.
Orbital Pain
  1. Orbital pseudotumor
  2. Retrobulbar neuritis
  3. Diabetic cranial nerve palsy
  4. Sinusitis
  5. Uncorrected refractive error.
Investigations for Headaches
  1. Enquire about
    • Location
    • Intensity
    • Duration
    • Frequency
    • Possible precipitating/relieving factors
  2. Age of onset
  3. Family history.
Ocular Examination
  1. Pupillary reactions
  2. Ocular motility
  3. Measurement of IOP
  4. Evaluation of visual field
  5. Cycloplegic refraction
  6. Ophthalmoscopy (direct and indirect) after pupil dilatation.
Systemic Examination
  1. Blood pressure
  2. Ear, nose and throat
  3. Nervous system
  4. Superficial temporal artery—Palpation to find tortuosity, thickening, tenderness and absence of palpation
  5. Only in selected cases, CT and MRI may be advised.
Watering may occur in children or in adults, the affection being painless or painful.
  1. In children
    1. Obstruction of nasolacrimal duct
    2. Congenital glaucoma
    3. Conjunctival or corneal foreign body
    4. Any irritative affection.
  2. In adults
    1. Minimum or no pain is present in conjunctivitis, blepharitis, dry eye, ectropion and abnormality of the lacrimal passages.
    2. Watering with pain is present in:
      • Foreign body in the conjunctiva and cornea
      • Trichiasis
      • Corneal erosions
      • Anterior uveitis.
Burning Sensation of Eyes
  1. Blepharitis
  2. Dry eye syndrome
  3. Conjunctivitis
  4. Inflamed pinguecula
  5. Inflamed pterygium.
Conjunctival Discharge
  1. Infective conjunctivitis
  2. Allergic conjunctivitis
  3. Canaliculitis
  4. Dacryocystitis.
Metamorphopsia, Micropsia and Macropsia
  • Metamorphopsia—distorsion of vision
  • Micropsia—objects appearing smaller
  • Macropsia—objects appearing larger.
  1. Astigmatism
  2. Corneal surface irregularity
  3. Retinal detachment
  4. Macular disease
  5. Migraine.
Double Vision (Diplopia)
  1. Uniocular—diplopia remains on covering the unaffected eye
    1. Incipient cataract
    2. Dislocated lens or lens implant
    3. Irregular astigmatism
    4. Improper correction of high astigmatism
    5. Multiple sclerosis
  2. Binocular—diplopia disappears when either eye is occluded
    1. Isolated 3rd, 4th or 6th cranial nerve palsy
    2. Internuclear ophthalmoplegia
    3. Abnormal retinal correspondence
    4. Myasthenia gravis-intermittent
    5. Large surgical overcorrection.
Horizontal, Vertical or Torsional Diplopia
In horizontal diplopia, the false image may be on the same side of the deviating eye (homonymous diplopia) or on the opposite side of the deviating eye (heteronymous or crossed diplopia).9
Itching of Eyes
  1. Allergic conjunctivitis
  2. Viral conjunctivitis
  3. Blepharitis
  4. Dry eye syndrome
  5. Topical drug allergy
  6. Following contact lens-wear.
Foreign Body Sensation
  1. Blepharitis
  2. Dry eye syndrome
  3. Trichiasis
  4. Corneal abrasion
  5. Corneal foreign body
  6. Superficial punctate keratitis.
  1. Corneal abrasion
  2. Corneal edema
  3. Anterior uveitis
  4. Albinism
  5. Aniridia.
Night Blindness
  1. Vitamin A deficiency
  2. Pigmentary retinal dystrophy
  3. Uncorrected myopia
  4. Choroideremia
  5. Gyrate atrophy
  6. Advanced glaucoma.
Day Blindness
  1. Central opacity of cornea, lens or vitreous
  2. Congenital deficiency of cones.
Spots in Front of the Eye(s)
  1. Posterior vitreous detachment
  2. Posterior uveitis
  3. Vitreous hemorrhage
  4. Retinal detachment
  5. Corneal opacity
  6. Migraine—Transient phenomenon.
Haloes Around Lights
  1. Corneal haziness
  2. Corneal edema
  3. Closed-angle glaucoma
  4. Cataract.
Flashes of Light (Photopsia)
  1. Retinal break
  2. Retinal detachment
  3. Posterior vitreous detachment
  4. Retinitis
  5. Migraine.
Chromatopsia (Colored Vision)
This may be:
  • Red—Erythropsia
  • Blue—Cyanopsia
  • Yellow—Xanthopsia
  • Green—Chloropsia.
  1. Erythropsia—May occur in vitreous or retinal hemorrhage, aphakia and postiridectomy.
  2. Cyanopsia—May occur after digitalis or atebrine therapy.
  3. Xanthopsia—May occur after IV fluorescein, jaundice, chlorothiazide and sulfonamide therapy.
  4. Chloropsia—May occur after griseofulvin therapy.
Ocular Signs
Whorl-like Opacity in the Corneal Epithelium
  1. Fabry's disease
  2. Prolonged use of chloroquine, indomethacin and phenothiazine.
Prominent Corneal Nerves
  1. Leprosy
  2. Neurofibromatosis
  3. Primary amyloidosis
  4. Keratoconus
  5. Fuchs’ endothelial corneal dystrophy
  6. Ichthyosis
  7. Failed corneal graft.
Heterochromic Irides
Heterochromia iridum is an affection in which the two irides have different colors. Heterochromia irides means part of the same iris shows different color from the remaining iris (Figs 1.4 and 1.5).
  1. Iris hyperchromia
    1. Nevus of Ota (oculodermal melanocytosis)
    2. Siderosis bulbi
    3. Pigmented iris tumors like nevus and melanoma
    4. Sturge-Weber syndrome
    5. Retained intraocular foreign body
    6. Following use of latanoprost.
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      Fig. 1.4: Heterochromia iridis in a child (Photo RN Sen, ECRC, Kolkata).
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      Fig. 1.5: The color of the right iris is blue except in one sector in the same patient (Photo RN Sen, ECRC, Kolkata).
  2. Hypochromia of iris
    1. Congenital as in Waardenburg's syndrome
    2. Horner's syndrome
    3. Fuchs’ heterochromic cyclitis.
Iridescent Lens Particles
  1. Myotonic dystrophy
  2. Hypothyroidism
  3. Hypocalcemia
  4. Familial
  5. Drugs.
Acute Rise of Intraocular Pressure
  1. Acute congestive glaucoma
  2. Inflammatory open-angle glaucoma
  3. Posner-Schlossman syndrome
  4. Malignant glaucoma
  5. Postoperative glaucoma
  6. Hyphema
  7. Retrobulbar hemorrhage.
Bone Corpuscle Pigment in Ocular Fundus (Fig. 1.6)
  1. Pigmentary dystrophy of the retina and associated syndromes.
  2. Disseminated chorioretinitis of syphilitic origin
  3. Aging retina
  4. Old vascular occlusion.
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Fig. 1.6: Bone corpuscle-like pigment in the fundus with waxy pallor of the vessels and narrowed arterioles in pigmentary retinal dystrophy.
Decreased Vision but Normal Fundus
  1. Retrobulbar neuritis
  2. Early retinal dystrophies—like Stargardt's syndrome and cone dystrophy
  3. Amblyopia
  4. Leber's congenital amaurosis
  5. Achromatopsia
  6. Congenital stationary night blindness
  7. Cortical visual impairment.
Differential Diagnosis
  1. Retrobulbar neuritis
    • Usually unilateral
    • Orbital pain with ocular movement
    • Relative afferent papillary defect
    • Defective color vision
    • Visual field defects—Central or centrocecal, arcuate or altitudinal.
  2. Stargardt's syndrome (fundus flavimaculatus)
    • Bilateral affection in child or young adult
    • Relatively normal-looking fundus
    • Atrophic macular degeneration.
  3. Amblyopia
    • Usually asymptomatic
    • Poor visual acuity not improved with any glass
    • Presence of crowding phenomenon (individual letters are better seen than the whole line).
  4. Leber's congenital amaurosis
    • Nystagmus-upbeat, i.e. vertical nystagmus with fast phase upward or roving
    • Abnormal or flat electroretinogram.
  5. Achromatopsia (rod monochromatism)
    • Total color blindness
    • Nystagmus
    • Photophobia.
  6. Congenital stationary night blindness
    • Night blindness
    • Myopia
    • Nystagmus.
  7. Cortical blindness (Anton's syndrome)
    • Bilateral severe visual loss
    • Normal pupillary responses
    • Check-up by neurologist
    • MRI of the brain.
Sheathing of the Retinal Veins (Periphlebitis)
  1. Pars planitis
  2. Eales’ disease
  3. Sarcoidosis
  4. Multiple sclerosis
  5. Tuberculosis
  6. Behçet syndrome
  7. Sickle-cell disease.
Embolus in the Ocular Fundus
The embolus may be:
  1. Platelet-fibrin (dull gray and elongated)—In carotid disease
  2. Cholesterol (yellow, at bifurcation of the arteries)—In carotid disease
  3. Calcium (dull white, on or around the disk)—In cardiac disease
  4. Lipid or air—As in Purtscher retinopathy
  5. Others like tumor cells and parasites.
Macular Exudates
  1. Diabetic retinopathy
  2. Malignant hypertension
  3. Choroidal neovascular membrane
  4. Central retinal vein thrombosis
  5. Papilledema
  6. Coats’ disease.
Chorioretinal Fold
  1. Hypotony
  2. Optic disk edema
  3. Choroidal tumors
  4. Following scleral buckling
  5. Dysthyroid ophthalmopathy
  6. Orbital pseudotumor.
Blind Spot Enlargement
  1. Papilledema
  2. Glaucoma
  3. Opaque nerve fibers
  4. Optic nerve drusen
  5. Optic nerve coloboma
  6. Myopic disk with crescent.
The ten different types are:
  1. Positive—Discovered by the patient
  2. Negative—Detected by the observer
  3. Central
  4. Arcuate (Bjerrum)
  5. Paracentral—Adjacent to the fixation point
  6. Pericentral—Around the fixation point
  7. Pericecal—Round the blind spot
  8. Paracecal—Near the blind spot
  9. Centrocecal—Between fixation point and blind spot
  10. Scintillating.
Central and Centrocecal Scotomas (Figs 1.7 and 1.8)
  1. Macular lesions
  2. Papillitis
  3. Retrobulbar neuritis
  4. Toxic agents
  5. Occipital lesion—Rare.
Arcuate (Bjerrum) Scotoma (Fig. 1.9)
This is narrower on temporal side and wider on nasal side of the field and follows nerve fiber bundle defect.17
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Fig. 1.7: Central scotoma.
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Fig. 1.8: Centrocecal scotoma.
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Fig. 1.9: Arcuate scotoma.
  1. Glaucoma
  2. Anterior ischemic optic neuropathy
  3. High myopia
  4. Optic disk drusen.
Altitudinal Hemianopia
Defect is detected in the upper or lower half of the visual field.
  1. Anterior ischemic optic neuropathy
  2. Hemibranch retinal artery or vein occlusion
  3. Glaucoma
  4. Optic nerve lesion
  5. Chiasmal lesion.
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Fig. 1.10: Bitemporal hemianopia in lesion of optic chiasma.
Binasal Hemianopia
Defects are present in the nasal half of visual field.
  1. Glaucoma
  2. Aneurysm of internal carotid artery
  3. Pituitary tumor with 3rd ventricle dilatation extending laterally
  4. Bilateral occipital lesion.
Bitemporal Hemianopia (Fig. 1.10)
Defects are found in each temporal half of the visual field.
  1. Pituitary adenoma
  2. Craniopharyngioma
  3. Meningioma of the
    • Olfactory groove
    • Sphenoid ridge
    • Suprasellar region
  4. Optic nerve glioma
  5. Aneurysm of the internal carotid artery
  6. Basal meningitis.
Homonymous Hemianopia (Fig. 1.11)
This is hemianopia affecting the right or left halves of the visual field.
  1. Lesions of the optic tract—Due to craniopharyngioma, pituitary tumor, aneurysm of the internal carotid artery, multiple sclerosis, etc.
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    Fig. 1.11: Left homonymous hemianopia in lesion of right optic tract, optic radiation or visual cortex.
  2. Temporoparietal lesions—Like vascular lesions (sudden onset) and tumors
  3. Occipital lesions include vascular lesions, tumors and demyelinating disease.
Constriction of the Peripheral Fields
  1. Glaucoma
  2. Pigmentary dystrophy of retina
  3. Chronic papilledema.
Quadrantanopia (Figs 1.121.14)
  • Sector-shaped defect bounded by vertical and horizontal radii. This may be unilateral or bilateral-homonymous or crossed.
  • In homonymous: Loss of one quadrant in the upper or lower and right or left visual fields in temporal, parietal or occipital lobe lesions.
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    Fig. 1.12: Left upper quadrantanopia due to lesion of anterior loop of right optic radiation.
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    Fig. 1.13: Left lower quadrantanopia due to involvement of upper part of right optic radiation.
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    Fig. 1.14: Left upper quadrantanopia due to involvement of anterior loop of optic radiation.
  • In crossed: Upper quadrant of one visual field and lower quadrant of the opposite field lost as in glaucoma and chiasmal compression.
Dilated Episcleral Vessels
It occurs due to blood in Schlemm's canal.
  1. Underlying uveal melanoma
  2. Carotidocavernous fistula
  3. Cavernous sinus thrombosis
  4. Ophthalmic vein thrombosis
  5. Sturge-Weber syndrome
  6. Untreated glaucoma
  7. Ocular hypotony
  8. Following gonioscopy.
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Fig. 1.15: Extrinsic muscle thickening in dysthyroid ophthalmopathy seen by A- and B-scan ultrasonography.
Decreased Scleral Rigidity
  1. High myopia
  2. Thyrotropic exophthalmos
  3. Drinking of water
  4. Use of strong miotic.
Extrinsic Muscle Thickening
  1. Dysthyroid ophthalmopathy (Fig. 1.15)
  2. Orbital pseudotumor
  3. Extension of lacrimal gland tumor to a muscle.
Ocular Hypotony
  1. Choroidal or ciliary body detachment
  2. Serous detachment of retina
  3. Intraocular operation
  4. Trauma
  5. Phthisis bulbi
  6. Diabetic coma
  7. Hyperosmotic agents, miotics or acetazolamide.
Progressive Hypermetropia
  1. Presbyopia
  2. Central serous detachment
  3. Hypoglycemia
  4. Orbital tumor pressing on the back surface of the eye.
Progressive Myopia
  1. High myopia
  2. Staphyloma
  3. Diabetes mellitus.
Color Blindness (Figs 1.16A and B)
  1. Inherited
    1. Trichromat—Red, green and blue anomalies
    2. Dichromat—Red, green and blue deficiencies
    3. Monochromat—Cone or rod deficient
    4. Turner's syndrome.
  2. Acquired
These include:
  1. Retrobulbar neuritis
  2. Age-related macular degeneration
  3. Glaucoma
  4. Papillitis.
Hyphema (Fig. 1.17)
  1. Posttraumatic or postoperative
  2. Herpes simplex or zoster iritis
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    Fig. 1.16A: Ishihara color vision plate–The patient with both normal color vision and defective color vision can equally recognize 12.
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    Fig. 1.16B: Ishihara color vision plate–The patient with normal color vision sees it as 74, but patient with defective color vision sees it as 21.
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    Fig. 1.17: Hyphema(Courtesy: Cipla).
  3. Intraocular tumor
  4. Blood dyscrasia.
Hypopyon (Fig. 1.18)
  1. Corneal ulcer
  2. Acute uveitis
  3. Endophthalmitis
  4. Retinoblastoma(pseudohypopyon).
Restricted Ocular Motility
  1. With proptosis and resistant to retropulsion
    1. Orbital mass
    2. Restrictive myopathy—As in dysthyroid ophthalmo­pathy
    3. Ocular motor nerve palsy
    4. Orbital fracture with entrapment of muscle.
  2. With resistance to retropulsion
    1. Ocular motor nerve palsy-isolated 4th, 6th or multiple
    2. Myasthenia gravis
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      Fig. 1.18: Bacterial corneal ulcer with hypopyon(Courtesy: Dr S Ghosh, ECRC, Kolkata).
    3. Superior orbital fissure syndrome
    4. Cavernous sinus thrombosis
    5. Chronic progressive external ophthalmoplegia
    6. Blow-out fracture of the orbit
    7. Duane's retraction syndrome.