Sign&;Symptom and Anatomy of Eye

EYE ANATOMY

Eye diagram

Eye Diagram

Cornea : powerful refracting surface, providing 2/3 of the eye's focusing powerConjunctiva is the thin, transparent tissue that covers the outer surface of the eye.  It begins at the outer edge of the cornea, covering the visible part of the sclera, and lining the inside of the eyelids.

The vitreous is a thick, transparent substance that fills the center of the eye. It is composed mainly of water and comprises about 2/3 of the eye's volume.The retina is a multi-layered sensory tissue. 6 million cones.: best in bright light , allow us to see color. 125 million rods : spread throughout the peripheral retina and function best in dim lighting. The rods are responsible for peripheral and night vision.

Vitreous and Retina

The macula is responsible for our critical focusing vision. The fovea is the very center of the macula. The macula allows us to appreciate detail and perform tasks that require central vision such reading.

The choroid lies between the retina and sclera.  It is composed of layers of blood vessels that nourish the back of the eye.  The choroid connects with the ciliary body toward the front of the eye and is attached to edges of the optic nerve at the back of the eye.

The light rays are bent, refracted and focused by the cornea, lens, and vitreous. The lens' job is to make sure the rays come to a sharp focus on the retina.

Aqueous - ciliary body behind the iris - pupillary space - anterior chamber - angle structuresThe angle : filter called the trabecular meshwork.  - tiny channel in the sclera called the Canal of Schlemm  - the eye's blood vessels.

Anterior Chamber Angle Structures

Names of various eye conditions

OCULAR SYMPTOMS

& SIGNS

Burning & Irritation

More common : Blepharitis, dry-eye syndrome, conjunctivitis (discharge or eyelid sticking additionally).

Less common : Corneal problem (fluorescein staining of the cornea usually), inflamed pterygium/pinguecula, episcleritis, superior limbic keratoconjunctivitis

Blepharitis

Episcleritis

Pterygium

Pinguecula

Decreased VisionDecrease Vision

Transient visual loss Transient visual loss

Vision returns to normal within 24 hours, usually in 1 hr.

More common :More common : Few seconds (usually bilateral): Papilledema. Few minutes: Amaurosis fugax [transient ischemic attack

(TIA); unilateral]Vertebrobasilar artery insufficiency (bilateral).

10 to 60 minutes: Migraine (with or without a subsequent headache).

Transient visual lossTransient visual loss

Less commonLess common • Impending central retinal vein occlusion• Ischemic optic neuropathy • Ocular ischemic syndrome (carotid occlusive disease)• Glaucoma • Sudden change in blood pressure • Central nervous system (CNS) lesion• Giant cell arteritis

Visual loss lasting longer than 24 hrs

Sudden, painless loss. More common :Retinal artery or vein occlusionIschemic optic neuropathyVitreous hemorrhage Retinal DetachmentOptic neuritis

Less common :Other retinal or CNS disease.

Retinal Detachment

Central retinal Vein occlusion

Gradual, painless lossGradual, painless loss

Over weeks, months, or yearsMore common : • Cataract • Refractive error• Open-angle glaucoma • Chronic retinal disease [age-related macular

degeneration (AMD), diabetic retinopathy]Less common : • Chronic corneal disease (e.g., corneal dystrophy)• Optic neuropathy/atrophy (e.g., CNS tumor).

Note : Always remember nonphysiologic visual loss.

Painful loss

• Acute angle-closure glaucoma• Optic neuritis (pain with eye movements)• Uveitis• Corneal hydrops (keratoconus).

Red EyeRed Eye

Discharge present

More common : Conjunctivitis, Ophthalmia neonatorum in infants, Blepharitis.

Less common: Acute allergic reaction, Dacryocystitis, Canaliculitis.

Marginal Ulcer

Fungal Keratitis

Bacterial Keratitis• Decrease vision• Pain• conj. Inflammation• corneal Ulcer• mucopurulent exudation w

ith stromal suppuration• A/C Hypopyon

Risk factors: trauma, older age, preexisting ocular disease, contact lens wear, contaminated ocular medication, surgery and systemic disease

No discharge present. More common : Subconjunctival hemorrhage, injected pterygium/ pingueculum, blepharitis, dry-eye syndrome.

Red Eye

PainPain

Pain (Ocular) Typically mild to moderate

• Dry-eye syndrome• Blepharitis• Conjunctivitis• Episcleritis• Inflamed pingueculum or pterygium• Foreign body (corneal or conjunctival)• Corneal disorder (superficial punctate keratitis)

Pain (Ocular) Typically moderate to severe:

• Corneal disorder (abrasion, erosion, infiltrate/ulcer)• Anterior uveitis• Scleritis• Acute angle-closure glaucoma.

• Sinusitis• Dry eyes• Orbital pseudotumor• Optic neuritis• Diabetic cranial nerve palsy.

Pain (orbital)

Photophobia

More common :Corneal abnormality (e.g., abrasion or edema) or anterior uveitis.

Less common: Conjunctivitis (mild photophobia), posterior uveitis, albinism, total color blindness, aniridia.

With normal eye examination: Migraine, meningitis, retrobulbar optic neuritis, subarachnoid hemorrhage, trigeminal neuralgia, or a lightly pigmented eye.

Distortion (of Vision)Distortion (of Vision)

Cataract, topical eye drops (miotics),Retinal detachmentMigraine (transient)CNS abnormality.

More common :Refractive errorMacular disease (e.g., central serous chorioretinopathy or AMD), Corneal irregularity

Less common :

Double Vision

Monocular Diplopia (The double vision remains when the uninvolved eye is occluded.)

More common: Refractive error, corneal opacity or irregularity, cataract.

Less common : Dislocated natural lens or lens implant, extra pupillary openings, macular disease, retinal detachment, nonphysiologic.

Binocular Diplopia

Typically intermittent: • Myasthenia gravis,

• Intermittent decompensation of an existing phoria.

(double vision is eliminated when either eye is occluded.)

Constant:• Isolated sixth-, third-, or

fourth-nerve palsy; • Orbital disease (e.g.,

thyroid eye disease, orbital inflammatory pseudotumor, tumor);

• Cavernous sinus/superior orbital fissure syndrome;

• Internuclear ophthalmoplegia,

• Other CNS lesions,

• Status post ocular surgery (e.g., residual anesthesia, displaced muscle);

• Status post trauma (e.g., orbital wall fracture with extraocular muscle entrapment, orbital edema);

• Spectacle problem.

Binocular double vision

Eyelid Crusting

More common: Blepharitis, meibomianitis, conjunctivitis.

Less common: Canaliculitis, nasolacrimal duct obstruction, dacryocystitis.

Eyelid Swelling

Associated with inflammation (usually erythematous)

More common :Hordeolum, blepharitis, conjunctivitis, preseptal or orbital cellulitis, trauma, contact dermatitis.Less common:Ectropion, corneal abnormality, urticaria/angioedema, insect bite, dacryoadenitis, erysipelas, eyelid or lacrimal gland mass.

Eyelid Swelling

Noninflammatory: • Chalazion• prolapse of orbital fat• laxity of the eyelid skin• cardiac, renal, or thyroid disease• eyelid or lacrimal gland mass.

• Fatigue, lack of sleep• Excess caffeine • Habit• Corneal or conjunctival

irritation (especially from an eyelash or cyst)

• Dry eye

• Blepharospasm (bilateral)• Hemifacial spasm • Albinism

Eyelid Twitch

Foreign-Body Sensation

Dry-eye syndrome, blepharitis, conjunctivitis, trichiasis, corneal abnormality (e.g., corneal abrasion or foreign body, recurrent erosion, superficial punctate keratitis), contact lens–related problem, episcleritis, pterygium, or pinguecular

Itchy Eye

Conjunctivitis (especially viral, vernal, and allergic), blepharitis, dry-eye syndrome, topical drug allergy or contact dermatitis, giant papillary conjunctivitis or another contact lens–related problem.

More common : Retinal break or detachment, posterior vitreous detachment, migraine, rapid eye movements (particularly in darkness).Less common: CNS (particularly occipital lobe) disorders

Flashes of Light

Retinal Detachment

Transient : Migraine. Permanent or long-standing. More common : Posterior vitreous detachment, posterior uveitis, vitreous hemorrhage, vitreous condensations/debris. Less common : Retinal detachment, corneal opacity.

Spots in Front of the Eyes

Night Blindness

More common : Refractive error (especially undercorrected myopia), advanced glaucoma, small pupil (especially from miotic drops), retinitis pigmentosa, congenital stationary night blindness, drugs (e.g., pheno-thiazines, chloroquine, quinine).

Less common : Vitamin A deficiency, gyrate atrophy, choroideremia.

Halos Around Lights

• Cataract• Acute angle-closure glaucoma• Corneal edema from another cause (e.g., corneal

endothelial dystrophy, aphakic/pseudophakic bullous keratopathy)

Tearing

Adults.

Pain present : Corneal abnormality (e.g., abrasion, foreign body/rust ring, recurrent erosion, edema), anterior uveitis, eyelash (trichiasis, entropion), cyst, or foreign body rubbing against the cornea, conjunctival abnormality (e.g., foreign body, laceration).

Tearing

Minimal or no pain present: Dry eye-syndrome, blepharitis, nasolacrimal duct obstruction, punctal occlusion or other tear drainage abnormality, ectropion, conjunctivitis (especially allergic and toxic), lacrimal sac mass or inflammation. Children:

Nasolacrimal duct obstruction, congenital glaucoma, corneal or conjunctival foreign body or other irritative disorder.

Adults.

Proptosis: Exophthalmos

Thyroid eye disease (Eyelid retraction and eyelid lag. Painless unless exposure keratopathy develops. Often bilateral. CT scan: Thickening of the extraocular muscles without involvement of the associated tendons.)

• Orbital inflammatory pseudotumor • Orbital cellulitis • Orbital tumors • Lacrimal gland tumors • Trauma (e.g., intraorbital foreign body, retrobulbar

hemorrhage; Orbital vasculitis• Mucormycosis• Varix

Proptosis: Exophthalmos

OCULAR SIGNS

Hypopyon

• Infectious corneal ulcer• Endophthalmitis• Severe iritis• Reaction to an intraocular lens or retained lens

protein after cataract surgery• Intraocular tumor necrosis [e.g., retinoblastoma (a

pseudohypopyon)]

•Band Keratopathy

•Arcus senilis

•Dilated Episcleral Vessels (in the Absence of Ocular Irritation or Pain)

Underlying uveal melanoma, Arteriovenous fistula (e.g., carotid–cavernous fistula), Polycythemia vera, leukemia, Ophthalmic vein or cavernous sinus thrombosis.

Membranous Conjunctivitis

(Removal of the membrane is difficult and causes bleeding).

Streptococci pneumococci; chemical burn;

ligneous conjunctivitis; Corynebacterium

diphtheriae; adenovirus or herpes simplex virus.

Pseudomembranous Conjunctivitis

(Removal of the membrane is easy, and no bleeding results.)All of the causes of membranous conjunctivitis, as well as ocular cicatricial pemphigoid, Stevens–Johnson syndrome, superior limbic keratoconjunctivitis, gonococci, staphylococci, chlamydia in newborns, and others.

Gonococcal Conjunctivitis

Pannus (Superficial Vascular Invasion of the Cornea)

Tight contact lens or contact lens overwear, phlyctenule, chlamydia (trachoma and inclusion conjunctivitis), superior limbic keratoconjunctivitis (micropannus only), staphylococcal hypersensitivity, vernal keratoconjunctivitis, herpes simplex virus, chemical burn, aniridia.

Large Papillae on the Superior Tarsus

Vernal or atopic conjunctivitis, giant papillary conjunctivitis, exposed suture, prosthesis-induced trachoma, superior limbic keratoconjunctivitis (fine papillae).

Symblepharon :

Fusion of the Palpebral Conjunctiva with Bulbar Conjunctiva

Ocular cicatricial pemphigoid, Stevens–Johnson syndrome, chemical burn, trauma, drugs, long-standing inflammation, epidermic keratoconjunctivitis, atopic conjunctivitis, radiation.

Eyelid Edema or SwellingMore common Orbital fat herniation from aging, conjunctivitis, allergy, chalazion, orbital disease.

Less common Cardiac disease, renal disease, urticaria/angioneurotic edema, dacryoadenitis, hypothyroidism, superior vena cava syndrome.

Eyelid Lesion

• Dermatochalasis, • Brow ptosis • Enophthalmos (traumatic blow-out fracture)• Phthisis bulbi, microphthalmia (small eye)• Chalazion or other eyelid tumor, eyelid edema

Pseudoptosis

More common : Aging (e.g., levator dehiscence)Following intraocular surgery or traumaCongenital.

Less common : Myasthenia gravisHorner’s syndromeThird-nerve palsy

Ptosis

Age-related macular degeneration (ARMD), Stargardt’s diseaseCone dystrophyChloroquine retinopathy

Bull’s-Eye Macular Lesion

Cotton-Wool Spots, Without Other Abnormalities (White Fluffy Lesions with Feathered Edges, Often Obscuring Retinal Vessels)

More common Acquired immunodeficiency syndrome (AIDS) retinopathy, hypertension, diabetes, collagen–vascular disease (e.g., systemic lupus erythematosus), retinal artery/arteriole occlusion.

Less common Retinal vein occlusion, cardiac valvular disease, carotid artery obstruction, chest trauma (Purtscher’s retinopathy), anemia, leukemia, lymphoma.

CMV retinitis

Embolus

Amaurosis Fugax, Branch Retinal Artery Occlusion or Central Retinal Artery Occlusion• Platelet-fibrin [dull gray and elongated (as opposed to round)]: Carotid disease.• Cholesterol (sparkling yellow, usually at an arterial bifurcation: Carotid disease). • Calcium (dull white, typically around or on the disc: Cardiac disease).

Macular Exudates

More common Diabetes, choroidal (subretinal) neovascular membrane, hypertension.

Less common Macroaneurysm, Coats’ disease (children), peripheral retinal capillary hemangioma, retinal vein occlusion, papilledema, radiation.

Normal Fundus in the Presence of Decreased Vision

Retrobulbar optic neuritis Cone degenerations Stargardt’s disease Fundus flavimaculatus Other optic neuropathy (tumor, alcohol/tobacco) Rod monochromatism Amblyopia Nonphysiologic visual loss

Neovascularization Neovascularization of the Irisof the Iris Diabetic retinopathy Central retinal vein or artery occlusion Branch retinal vein occlusion Ocular ischemic syndrome (carotid occlusive disease) Chronic uveitis Chronic retinal detachment Intraocular tumor (e.G., Retinoblastoma) Other retinal vascular disease

Neuroophthalmic Abnormalities

Afferent Pupillary Defect

Severe (2 to 3+): Optic nerve disease (e.g., ischemic optic neuropathy, optic neuritis, tumor, glaucoma); central retinal artery or vein occlusion; less commonly, a lesion of the optic chiasm/tract. Mild (1+): Any of the above, amblyopia, macular degeneration, branch retinal vein or artery occlusion, retinal detachment, or other retinal disease.

Anisocoria (Pupils of Different Sizes)

Without exophthalmos • Isolated third-, fourth-, or sixth-nerve palsy; multiple

ocular motor nerve palsies • Superior Orbital Fissure Syndrome• Myasthenia gravis; chronic progressive external

ophthalmoplegia; orbital blow-out fracture with muscle entrapment; ophthalmoplegic migraine

Duane’s syndrome

Limitation of Ocular Motility

Optic Disc Atrophy

More common : Glaucoma; following central retinal vein or artery occlusion; ischemic optic neuropathy; chronic optic neuritis; chronic papilledema; compression of the optic nerve, chiasm, or tract by a tumor or aneurysm; traumatic optic neuropathy.

Less common : Syphilis, retinal degeneration (e.g., retinitis pigmentosa), toxic/metabolic optic neuropathy, Leber’s optic atrophy, Leber’s congenital amaurosis, retinal storage disease radiation neuropathy, congenital or hereditary optic atrophy (nystagmus almost always present in the congenital forms).

Optic Disc Swelling (Edema)Optic Disc Swelling (Edema)

Swollen, hyperemic disc, blurring of disc margin: Papilledema• Intracranial tumor• Hydrocephalus• Pseudotumor cerebri• Intracranial hematoma & hemorrhage• Brain abscess• Meningitis & encephalitis• DDX: HT retinopathy, papillitis, tumor, diabetic

Extraocular Muscle Extraocular Muscle Thickening on CT ScanThickening on CT Scan

More common : Thyroid orbitopathy, orbital inflammatory pseudotumor.

Less common : Tumor lymphoma, metastasis, or spread of lacrimal gland tumor to muscle), carotid–cavernous fistula, cavernous hemangioma (usually appears in the muscle cone without muscle thickening), rhabdomyosarcoma

OrbitOrbit

Pediatrics(White Pupillary Reflex)• Retinoblastoma• Toxocariasis• Coat’s Disease• Congenital cataract• ROP

Leukocoria

Nystagmus in Infancy

Congenital nystagmus, albinism, Leber’s congenital amaurosis, CNS (thalamic) injury, spasmus nutans, optic nerve or chiasmal glioma, optic nerve hypoplasia, congenital cataracts, aniridia, congenital corneal opacities.

Refractive Problems

Progressive HyperopiaOrbital tumor pressing on the posterior surface of the eye, serous elevation of the retina (e.g., central serous chorioretinopathy), posterior scleritis, presbyopia, hypoglycemia, cataracts.

Progressive MyopiaHigh (pathologic) myopia, diabetes, cataract, use of miotic drops, staphyloma and elongation of the globe, medications (e.g., sulfa drugs, tetracycline), childhood (physiologic).

Asteroid hyalosis

Synchysis scintillans

Vitreous hemorrhage

Vitritis or posterior uveitis

Pars planitis

Sarcoidosis

Age-related vitreous degeneration

Vitreous OpacitiesVitreous Opacities