Red Eye, Conjuctivitis, Vision Loss

RED EYE AND VISION LOSS LONG
EXAMINATION
Points: 43/5 5
A major risk for the development of bacterial keratitis is

(1/1 Points)
Age
Contact lens wear
diabetes mellitus
none of the above
A degenerative lesion of the bulbar conjunctiva that occurs adjacent to the limbus in the
interpalpebral zone most often nasally
(1/1 Points)
phlytenulosis
conjunctival granuloma
chalazion
pinguecula
What layer of the cornea regenerates rapidly following injury?

(1/1 Points)
Epithelium .“
Bowman's membrane
corneal stroma
endothelium
What are the features of anterior uveitis is

(1/1 Points)
photophobia
redness
both
neither
Foreign body sensation can be produced by all of the following EXCEPT:
(1/1 Points)
Viral conjunctivitis
Contact lens wear
Trichiasis
NONE OF THE ABOVE
Sudden persistent painless loss of vision

(0/1 Points)
cataract
primary open angle glaucoma
optic neuritis
central retinal vein occlusion +“
The effective treatment for Herpes Zoster ophthalmicus is

(1/1 Points)
metronidazole
acyclovir
natamycin
artificial tears.
Swelling of the disc and visual loss in an older adult could be due to
(0/1 Points)
temporal arteritis .“
both
neither
Hollenhorst plaque seen in retinal vein occlusions is a:

(1/1 Points)
calcific embolus
fibrin embolus
cholesterolembolus
none of the above

ti}
Purulent discharge can be seen in

(1/1 Points)
viral conjunctivitis
bacterial conjunctivitis ~~
allergic conjunctivitis
dysfunctional tear syndrome
Which of the following term refers to purulent matter in the anterior chamber?
(1/1 Points)
hypopyon .~%
hyphema
synechia
kerattis
A 36 year old man complained of a 3-day history of redness, severe pain, and intense
sensitivity to light of his left eye. He denies any trauma to the affected eye. Which among the
following signs will convince you that the patient DOES NOT have conjunctivitis?
(1/1 Points)
Visual acuity of 20/200
Ciliary flush
both
neither
Pharyngoconjunctival fever ( conjunctivitis with fever and sore throat) is associated with what
strain/s?
(1/1 Points)
Adenovirus 3
Adenovirus 11
Both
Neither
Disc swelling, venous engorgement, cotton wool spots, and diffuse retinal hemorrhages are
characteristic findings in
(1/1 Points)
central retinal vein occlusion +“
central retinal artery occlusion
papilledema
none of the above

The histology of pterygium include/s:
(1/1 Points)
precancerous stage
fibrovascular overgrowth of the bulbar conjunctiva .~
both
neither
x
|
An inflammatory adhesion between iris and the peripheral corneal endothelium is termed as
(0/1 Points)
Peripheral corneal synechia .~“
Posterior synechia
hypopyon
none of the above
Vision in a moderate to advanced case of glaucoma could be described as:

(1/1 Points)
curtaining of vision
tunneling of vision “
wavy Vision
none of the above
iT}
An inflammatory adhesion between iris and the anterior surface of the lens capsule is termed
as
(1/1 Points)
Peripheral corneal endothelium
Posterior synechia ~~
hypopyon
none of the above
The following may lead to the formation of pterygium EXCEPT:

(0/1 Points)
exposure to ultraviolet rays
living in trapical area
frequent exposure to smoke
none of the above .~“

rat)
A hyperacute, hyperpurulent discharge is a clinical manifestation of

(1/1 Points)
gonococcal conjunctivitis .~
adenoviral conjunctivitis
chlamydial conjunctivitis
ea
Prolonged use of topical ophthalmic anesthetics can cause?

(1/1 Points)
cormeal damage ~~”
cataract
both
neither
Functional disorder is defined as loss of vision with organic basis. TRUE or FALSE?
(1/1 Points)
TRUE
FALSE \/%
Trantas dots can be seen in Vernal Keratoconjunctivitis . These characteristic cells are
composed of:
(1/1 Points)
neutrophils
macrophages
lymphocytes.
none of the above ~~“
pa
The presence of symblepharon can be seen in

(1/1 Points)
ocular cicatricial pemphigoid
stevens-johnson syndrome
Both
Neither
Ankyloblepharon refers to the adhesion of the bulbar and palpebral conjunctiva. TRUE or
FALSE?
(0/1 Points)
True
False
Discharge seen in chlamydial conjunctivitis is normally described as:

(1/1 Points)
mucopurulent
watery
reddish
none of the above
x
Ei
Causes of acute visual loss, EXCEPT:
(0/1 Points)
Migraine
Vitreous hemorrhage
Retinitis pigmentosa .%
72 year old male farmer who has been experiencing chronic eye redness for 2 years. What is
the most likely diagnosis?
(0/1 Points)
‘Conjunctival squamous cell carcinoma
‘Conjunctival lymphoma
Pterygium
Pinguecula
A9 year old boy presents with a grossly swollen eyelid. What finding is most characteristic of
orbital cellulitis?
(1/1 Points)
Proptosis .~“
Eyelid edema
rhamacie
ciliary injection
30
The most common cause of red eye and chronic eye proptosis in an adult is:
(1/1 Points)
Thyroid orbitopathy ~~
Orbital cellulitis
Orbital tumor
none of the above
Ey
A75 year old male came in due to” salmon patch” appearance in the bulbar conjunctiva for
almost 2 years. Your most likely diagnosis will be ?
(1/1 Points)
conjunctival squamous papilloma
conjunctival lymphoma .“
chalazion
none of the above
A 53 year old female with a history of recent bronchial asthma attack woke up this morning
with a red eye and has no other symptoms. Upon examination, you note a temporal sector of
the eye that is red without injection of the conjunctival vessels. What is your most likely
diagnosis?
(0/1 Points)
Pinguecula
Conjunctivitis
Subconjunctival hemorrhage
scleritis
AAS year old farmer presents with a wing-like structure found at the nasal side of the cornea
at the palpebral fissure. What is your diagnosis?
(1/1 Points)
pinguecula
pterygium
episcleritis
none of the above
Be
A branch-like lesion( dendritiform) in the cornea is secondary to?

(1/1 Points)
Herpetic Keratitis .“
Fungal Keratitis
Acanthamoeba keratitis
None of the above
x
Ei
Treatment for allergic conjunctivitis
(0/1 Points)
cetirizine 10 mg tablet
olopatadine eyedrops
both .~%
neither
Bis]
Monocular loss of vision developing over hours to days / no abnormalities seen in ophthalmic
examination associated with pain on movement of eyes
(1/1 Points)
retrobulbar neuritis .“
optic neuritis
papilledema
none of the above
Management of central retinal artery occlusion ( CRAO) include the following , EXCEPT:
(1/1 Points)
ocular massage
intravenous acetazolamide
both
neither
re}
Most frequent etiologic agent of conjunctivitis

(1/1 Points)
adenovirus
herpes simplex
both
neither
Which of the following term refers to the presence of red blood cells in the anterior chamber?
(1/1 Points)
hypopyon
hyphema
synechia
kerattis
Trachoma, which is one of the leading causes of preventable irreversible blindness in the world
is usually caused by:
(1/1 Points)
Chlamydia .“
Corynebacterium
Both
Neither
Symptom of macular disorder

(1/1 Points)
tunneling of vision
wavy vision 7
none of the above
x
42
All of the following can be caused by chlamydial infection EXCEPT:

(0/1 Points)
inclusion conjunctivitis
trachoma
both ./
neither
Which among the following would manifest with a palpable preauricular lymphadenopathy
(1/1 Points)
both
neither
A 35-year patients with a hyperpurulent discharge of 1 day duration, marked chemosis of the
bulbar conjunctiva and clear cornea. What is your tentative diagnosis?
(1/1 Points)
Adenoviral conjunctivitis
herpes simplex keratoconjuntivitis

gonococcal conjunctivitis .~
The color of the fluorescein staining in corneal ulcer is

(1/1 Points)
Green 7
Purple
Yellow
Magenta
defect of central vision in which the shapes of objects appear distorted

(0/1 Points)
dyschromatopsia
metamorphopsia .“
heteromatopia
none of the above
Cherry-red spot is seen in:

(1/1 Points)
central retinal artery oclusion .“
central retinal vein occlusion
papilledema
none of the above
Subconjunctival hemorrhage represents an accumulation of blood

(1/1 Points)
within the anterior chamber
underneath the conjunctiva .~
in the vitreous
behind the retina
x
Indication for surgery in this eye condition include/s:
(0/1 Points)
induced astigmatism
bothersome epiphora
both
neither
Schirmer's test is used for diagnosing

(1/1 Points)
Dry eye syndrome .“
glaucoma
corneal abrasion
uveitis
Ey
The relative normal intraocular pressure (mmHg) is?

(1/1 Points)
5-11
10-21
22-30
none of the above
Symptom of retinal detachment

(1/1 Points)
curtaining of vision ~
tunneling of vision
wavy vision
none of the above
A recurrent bilateral conjunctivitis occurring with the onset of hot weather in 6 year old boy
with symptoms of burning, itching, and lacrimation with large flat-topped cobblestone
papillae raised areas in palpebral conjunctiva
(1/1 Points)
vernal keratoconjunctivitis .“
phlyctenular conjunctivitis
trachoma
none of the above

@ optic neuritis ~
oO retinal detachment
(> both
oO none of the above

5/26/22, 11:43 AM RED EYE & VISION LOSS LE.May 26, 2022
RED EYE & VISION LOSS LE.May 26,

2022

Hi, Shomesh. When you submit this form, the owner will see your name and email address.
Prolonged use of topical corticosteroids can cause:

(1 Point)
neither
cataract
both
corneal damage
A technique used to differentiate angle closure glaucoma from an open angle

glaucoma by viewing the anatomical angle formed between the eye's cornea
and iris
(1 Point)
Tonometry
Perimetry
Floumetry
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Gonioscopy
A major risk for the development of bacterial keratitis is

(1 Point)
Contact lens wear
none of the above
diabetes mellitus
Age
A hyperacute, hyperpurulent discharge is a clinical manifestation of

(1 Point)
gonococcal conjunctivitis
Sudden painful loss of vision that may be associated with multiple sclerosis
could be due to
(1 Point)
optic neuritis
none of the above
retinal detachment
both
A 36 year old man complained of a 3-day history of redness, severe pain, and
intense sensitivity to light of his left eye. He denies any trauma to the affected
eye. Which among the following signs will convince you that the patient DOES
NOT have conjunctivitis?
(1 Point)
neither
both
Ciliary flush
Eye discharge seen in allergic conjunctivitis is commonly described as:

(1 Point)
watery stringy
mucopurulent
none of the above
reddish
An inflammatory adhesion between iris and the peripheral corneal endothelium

is termed as
(1 Point)
none of the above
Posterior synechia
hypopyon
Peripheral corneal synechia
Most frequent etiologic agent of conjunctivitis

(1 Point)
both
herpes simplex
neither
adenovirus
10
Pharyngoconjunctival fever ( conjunctivitis with fever and sore throat) is

associated with what strain/s?
(1 Point)
Both
Adenovirus 11
Neither
Adenovirus 3
11
Management of central retinal artery occlusion ( CRAO) include the following ,

EXCEPT:
(1 Point)
both
neither
ocular massage
12
Vision in a moderate to advanced case of glaucoma could be described as:

(1 Point)
none of the above
tunneling of vision
wavy vision
13
The following are indications in pterygium excision ,EXCEPT:

(1 Point)
Bothersome tearing
None of the above
Significant astigmastim
If the pterygium is obscuring the visual axis
14
A 45 year old farmer presents with a wing-like structure found at the nasal side
of the cornea at the palpebral fissure. What is your diagnosis?
(1 Point)
pterygium
pinguecula
episcleritis
none of the above
15
True of Giant Cell Arteritis EXCEPT

(1 Point)
Symptoms include headache and pain over the temples
Treatment is typically with high doses of steroids
None of the above
It is an inflammation of the of small blood vessels
16
Trachoma, which is one of the leading causes of preventable irreversible

blindness in the world is usually caused by:
(1 Point)
Chlamydia
Corynebacterium
Neither
Both
17
Functional disorder is defined as loss of vision with organic basis. TRUE or

FALSE?
(1 Point)
FALSE
TRUE
18
A 35-year patients with a hyperpurulent discharge of 1 day duration, marked

chemosis of the bulbar conjunctiva and clear cornea. What is your tentative
diagnosis?
(1 Point)
19
72 year old male farmer who has been experiencing chronic eye redness for 2
years. What is the most likely diagnosis?
(1 Point)
Conjunctival lymphoma
Conjunctival squamous cell carcinoma
Pterygium
Pinguecula
20
What sign/symptom can be associated with a Subconjunctival hemorrhage?

(1 Point)
sneezing
photophobia
orbital pain
floaters
21
Symptom of macular disorder

(1 Point)
none of the above
tunneling of vision
wavy vision metamorphasia
22
Cherry-red spot is seen in:

(1 Point)
papilledema
central retinal artery oclusion

none of the above
23
Which of the following statement/s is true?

(1 Point)
Episcleritis is relatively common, benign and self limiting
Episcleritis is an inflammation of the superficial episcleral ;layer of the eye.
All of the above
Episcleritis blanches with 10% Phenylephrine drops
24
All of the following can be caused by chlamydial infection EXCEPT:

(1 Point)
trachoma
neither
both
25
Diagnosis for the given fungus photo?

(1 Point)
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none of the above
papilledema
26
Trantas dots can be seen in Vernal Keratoconjunctivitis . These characteristic

cells are composed of:
(1 Point)
neutrophils
lymphocytes
eosinophils
macrophages
27
All of the statements are true regarding the aqueous humor outflow :
(1 Point)
Neither
Trabecular outflow constitutes majority of the mechanism of how the aqueous humor exits the
eye
Uveoscleral outflow constitutes minority of the mechanism of how the aqueous humor exits th
eye i
Both
28
Red painful eye with purulent discharge and decreased vision, discrete corneal
opacity seen with penlight
(1 Point)
ruptured globe
acute angle-closure glaucoma
corneal ulcer
orbital cellulitis
29
The effective treatment for Herpes Zoster ophthalmicus is

(1 Point)
artificial tears
metronidazole
acyclovir
natamycin
30
A 59 year-old asian female presents with a sudden increase of intraocular

pressure to 55 mmHg in the left eye. Gonioscopic examination demonstrates a
closed angle with trabecular meshwork obstruction. Which of the following is
NOT a likely presenting symptom in this patient:
(1 Point)
halos around lights
doubling of vision
nausea/vomitin
ocular pain
31
Foreign body sensation can be produced by all of the following EXCEPT:

(1 Point)
Trichiasis
NONE OF THE ABOVE
Contact lens wear
32
Which of the following term refers to purulent matter in the anterior chamber?
(1 Point)
kerattis
hypopyon
hyphema
synechia
33
The relative normal intraocular pressure ( mmHg) is?

(1 Point)
10-21
5-11
22-30
none of the above
34
Ankyloblepharon refers to the adhesion of the bulbar and palpebral

conjunctiva. TRUE or FALSE?
(1 Point)
False
True
35
What is not a typical exam finding in conjunctivitis?

(1 Point)
anterior chamber cell and flare
Subepithelial corneal infiltrate
Red conjunctiva
Eyelid erythema
36
Symptom of retinal detachment

(1 Point)
tunneling of vision
none of the above
wavy vision
37
Indication for surgery in this eye condition include/s:

(1 Point)
induced astigmatism
both
bothersome epiphora
neither
38
Subconjunctival hemorrhage represents an accumulation of blood

(1 Point)
behind the retina
in the vitreous
underneath the conjunctiva
39
The most common cause of red eye and chronic eye proptosis in an adult is:
(1 Point)
Thyroid orbitopathy
Orbital tumor
Orbital cellulitis
none of the above
40
Which of the following term refers to the presence of red blood cells in the
anterior chamber?
(1 Point)
synechia
kerattis
hyphema
hypopyon
41
Patient with this condition may complain of burning, dryness , foreign body
sensation, blurred vision and photophobia that often worsens as the day
progresses and is exacerbated by dry, windy weather.
(1 Point)
chalazion
episcleritis
keratoconjunctivitis sica
acute dacryocystitis
42
Hollenhorst plaque seen in retinal vein occlusions is a:

(1 Point)
none of the above
fibrin embolus
calcific embolus
cholesterol embolus
43
An inflammatory adhesion between iris and the anterior surface of the lens
capsule is termed as
(1 Point)
hypopyon
Posterior synechia
none of the above
44
A recurrent bilateral conjunctivitis occurring with the onset of hot weather in 6

year old boy with symptoms of burning, itching, and lacrimation with large flat-
topped cobblestone papillae raised areas in palpebral conjunctiva
(1 Point)
vernal keratoconjunctivitis
none of the above
trachoma
45
The histology of pterygium include/s:

(1 Point)
fibrovascular overgrowth of the bulbar conjunctiva
neither
precancerous stage
both
46
A 75 year old male came in due to" salmon patch" appearance in the bulbar
conjunctiva for almost 2 years. Your most likely diagnosis will be ?
(1 Point)
none of the above
chalazion
conjunctival lymphoma
47
Treatment for allergic conjunctivitis

(1 Point)
olopatadine eyedrops
neither
both
cetirizine 10 mg tablet
48
What does a pupil typically look like in acute angle closure glaucoma?
(1 Point)
miotic
fixed and mid-dilated
None of the above
tear-drop shaped
49
defect of central vision in which the shapes of objects appear distorted

(1 Point)
dyschromatopsia
none of the above
metamorphopsia
heteromatopia
50
What layer of the cornea regenerates rapidly following injury?

(1 Point)
Bowman's membrane
corneal stroma
endothelium
Epithelium
51
Purulent discharge can be seen in

(1 Point)
bacterial conjunctivitis
52
What is the most common ocular sign in thyroid-associated orbitopathy?

(1 Point)
Proptosis
Exposure keratitis
chemosis
Lid retraction ( Darlymple sign)
53
Culture media for Neisseria gonorrhea:

(1 Point)
both
chocolate agar plate
neither
Thayer-Martin media
54
A degenerative lesion of the bulbar conjunctiva that occurs adjacent to the

limbus in the interpalpebral zone most often nasally
(1 Point)
chalazion
pinguecula
phlytenulosis
55
A branch-like lesion( dendritiform) in the cornea is secondary to?

(1 Point)
Herpetic Keratitis
Fungal Keratitis
None of the above
56
All of the following statements are true about uveitis except:

(1 Point)
triad of pain, glared eye redness is usually present
none of the above
cycloplegia eyedrops are part of the medical management
Mainstay of treatment is corticosteroids
57
Ankyloblepharon is an adhesion between

(1 Point)
none of the above
Bulbar conjunctiva and palpepbral conjunctiva
iris and lens
Upper eyelid and lower eyelid
58
Monocular loss of vision developing over hours to days / no abnormalities seen

in ophthalmic examination associated with pain on movement of eyes
(1 Point)
optic neuritis
papilledema
retrobulbar neuritis
none of the above
59
Causes of acute visual loss, EXCEPT:

(1 Point)
Retinitis pigmentosa
Migraine
Vitreous hemorrhage
60
Swelling of the disc and visual loss in an older adult could be due to
(1 Point)
neither
both
temporal arteritis
61
Damaged to this layer of the cornea following injury, inflammation, high

intraocular pressure results in corneal clouding from edema
(1 Point)
descemet's membrane
epithelium
bowman's membrane
none of the above
endothelium
62
An elevation in the intraocular pressure is not necessarily present in the

diagnosis of glaucoma. True or false?
(1 Point)
True
False
63
Schirmer's test is used for diagnosing

(1 Point)
glaucoma
corneal abrasion
Dry eye syndrome
uveitis
64
The following may lead to the formation of pterygium EXCEPT:

(1 Point)
none of the above
living in tropical area
65
Which among the following would NOT manifest with a palpable preauricular
lymphadenopathy
(1 Point)
Neisseria gonorrhea
neither
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9/10/2020 RED EYE AND VISION LOSS LONG EXAMINATION
RED EYE AND VISION LOSS LONG

EXAMINATION

Hi Dabhi, when you submit this form, the owner will be able to see your name and email address.
1. A 53 year old female with a history of recent bronchial asthma attack woke up this
morning with a red eye and has no other symptoms. Upon examination, you note
a temporal sector of the eye that is red without injection of the conjunctival
vessels. What is your most likely diagnosis?
(1 Point)
scleritis
Subconjunctival hemorrhage
Conjunctivitis
Pinguecula
2. Which among the following would manifest with a palpable preauricular

lymphadenopathy
(1 Point)
neither
both
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3. A degenerative lesion of the bulbar conjunctiva that occurs adjacent to the limbus
in the interpalpebral zone most often nasally
(1 Point)
chalazion
phlytenulosis
pinguecula
4. Monocular loss of vision developing over hours to days / no abnormalities seen in

ophthalmic examination associated with pain on movement of eyes
(1 Point)
optic neuritis
retrobulbar neuritis
papilledema
none of the above
5. Swelling of the disc and visual loss in an older adult could be due to
(1 Point)
temporal arteritis
neither
both
6. A 35-year patients with a hyperpurulent discharge of 1 day duration, marked

chemosis of the bulbar conjunctiva and clear cornea. What is your tentative
diagnosis?
(1 Point)
7. Symptom of macular disorder

(1 Point)
tunneling of vision
none of the above
wavy vision
8. Disc swelling, venous engorgement, cotton wool spots, and diffuse retinal
hemorrhages are characteristic findings in
(1 Point)
papilledema
none of the above
9. Functional disorder is defined as loss of vision with organic basis. TRUE or FALSE?
(1 Point)
TRUE
FALSE
10. Which of the following term refers to the presence of red blood cells in the
anterior chamber?
(1 Point)
synechia
hypopyon
kerattis
hyphema
11. The histology of pterygium include/s:

(1 Point)
neither
fibrovascular overgrowth of the bulbar conjunctiva
precancerous stage
both
12. A branch-like lesion( dendritiform) in the cornea is secondary to?

(1 Point)
None of the above
Herpetic Keratitis
Fungal Keratitis
13. Most frequent etiologic agent of conjunctivitis

(1 Point)
adenovirus
neither
both
herpes simplex
14. Vision in a moderate to advanced case of glaucoma could be described as:

(1 Point)
none of the above
wavy vision
tunneling of vision
15. A hyperacute, hyperpurulent discharge is a clinical manifestation of

(1 Point)
16. Prolonged use of topical ophthalmic anesthetics can cause?

(1 Point)
corneal damage
neither
both
cataract
17. Symptom of retinal detachment

(1 Point)
tunneling of vision
none of the above
wavy vision
18. An inflammatory adhesion between iris and the anterior surface of the lens
capsule is termed as
(1 Point)
hypopyon
Posterior synechia
none of the above
19. The relative normal intraocular pressure ( mmHg) is?

(1 Point)
10-21
22-30
none of the above
5-11
20. Purulent discharge can be seen in

(1 Point)
bacterial conjunctivitis
21. Cherry-red spot is seen in:

(1 Point)
central retinal artery oclusion
papilledema
none of the above
22. The effective treatment for Herpes Zoster ophthalmicus is

(1 Point)
artificial tears
natamycin
metronidazole
acyclovir
23. All of the following can be caused by chlamydial infection EXCEPT:

(1 Point)
neither
trachoma
both
24. Pharyngoconjunctival fever ( conjunctivitis with fever and sore throat) is associated
with what strain/s?
(1 Point)
Neither
Both
Adenovirus 3
Adenovirus 11
25. What are the features of anterior uveitis is

(1 Point)
redness
both
photophobia
neither
26. Trachoma, which is one of the leading causes of preventable irreversible blindness
in the world is usually caused by:
(1 Point)
Both
Neither
Corynebacterium
Chlamydia
27. The presence of symblepharon can be seen in

(1 Point)
ocular cicatricial pemphigoid
Both
stevens-johnson syndrome
Neither
28. Subconjunctival hemorrhage represents an accumulation of blood

(1 Point)
underneath the conjunctiva
behind the retina
in the vitreous
29. Sudden persistent painless loss of vision

(1 Point)
cataract
optic neuritis
30. A 9 year old boy presents with a grossly swollen eyelid. What finding is most
characteristic of orbital cellulitis?
(1 Point)
Eyelid edema
ciliary injection
chemosis
Proptosis
31. A recurrent bilateral conjunctivitis occurring with the onset of hot weather in 6
year old boy with symptoms of burning, itching, and lacrimation with large flat-
topped cobblestone papillae raised areas in palpebral conjunctiva
(1 Point)
trachoma
none of the above
vernal keratoconjunctivitis
32. Ankyloblepharon refers to the adhesion of the bulbar and palpebral conjunctiva.
TRUE or FALSE?
(1 Point)
True
False
33. The color of the fluorescein staining in corneal ulcer is

(1 Point)
Magenta
Purple
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Green
Yellow
34. What layer of the cornea regenerates rapidly following injury?

(1 Point)
Bowman's membrane
corneal stroma
endothelium
Epithelium
35. Hollenhorst plaque seen in retinal vein occlusions is a:

(1 Point)
calcific embolus
none of the above
cholesterol embolus
fibrin embolus
36. Sudden painful loss of vision that may be associated with multiple sclerosis could
be due to
(1 Point)
both
none of the above
optic neuritis
retinal detachment
37. Discharge seen in chlamydial conjunctivitis is normally described as:

(1 Point)
watery
reddish
none of the above
mucopurulent
38. An inflammatory adhesion between iris and the peripheral corneal endothelium is
termed as
(1 Point)
none of the above
hypopyon
Posterior synechia
39. Causes of acute visual loss, EXCEPT:

(1 Point)
Vitreous hemorrhage
Migraine
Retinitis pigmentosa
40. Schirmer's test is used for diagnosing

(1 Point)
uveitis
Dry eye syndrome
corneal abrasion
glaucoma
41. One of the indications in pterygium excision is a significant induced astigmatism.

True or false
(1 Point)
False
True
42. The most common cause of red eye and chronic eye proptosis in an adult is:
(1 Point)
none of the above
Thyroid orbitopathy
Orbital tumor
Orbital cellulitis
43. A 36 year old man complained of a 3-day history of redness, severe pain, and
intense sensitivity to light of his left eye. He denies any trauma to the affected eye.
Which among the following signs will convince you that the patient DOES NOT
have conjunctivitis?
(1 Point)
both
neither
Ciliary flush
44. Trantas dots can be seen in Vernal Keratoconjunctivitis . These characteristic cells
are composed of:
(1 Point)
lymphocytes
none of the above
neutrophils
macrophages
45. A 45 year old farmer presents with a wing-like structure found at the nasal side of
the cornea at the palpebral fissure. What is your diagnosis?
(1 Point)
pinguecula
pterygium
episcleritis
none of the above
46. Management of central retinal artery occlusion ( CRAO) include the following ,
EXCEPT:
(1 Point)
neither
both
ocular massage
47. Which of the following term refers to purulent matter in the anterior chamber?
(1 Point)
synechia
hyphema
hypopyon
kerattis
48. A 75 year old male came in due to" salmon patch" appearance in the bulbar
conjunctiva for almost 2 years. Your most likely diagnosis will be ?
(1 Point)
conjunctival lymphoma
chalazion
none of the above
49. Foreign body sensation can be produced by all of the following EXCEPT:
(1 Point)
NONE OF THE ABOVE
Contact lens wear
Trichiasis
50. A major risk for the development of bacterial keratitis is

(1 Point)
Contact lens wear
diabetes mellitus
Age
none of the above
51. The following may lead to the formation of pterygium EXCEPT:

(1 Point)
living in tropical area
none of the above
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RED EYE:
Basic Information and How to Identify
Disorders Associated with Red Eye
By: Dr. Carmina M. Lim
March 29,2022
 
Red Eye: Basic Information & How to Identify Disorders Associated with Red Eye
RED EYE
❑ Refers to hyperemia, or injection of the superficially
visible vessels of the conjunctiva, episclera, or sclera.
❑ Hyperemia can be caused by disorders of these outer

structures or of the cornea, iris, ciliary body, and ocular
adnexae.
❑ An accurate history followed by exam will aid in narrowing

the differential diagnosis and instituting appropriate
management.
RED EYE : BASIC INFORMATION
A. History
B. How to examine
HISTORY:
When a patient presents with a red eye, taking a
thorough history is essential.
Occasionally a red eye may indicate a systemic disease;

therefore, a complete medical history and review of
systems is required.

Additional questions to ask include:

Was the onset sudden or progressive?

What is the timeline of symptoms; hours, days, or intermittent?

Any family members with a red eye recently( ie, exposure to
people with the same symptoms)?

Is the patient using any over-the-counter or prescription eye
medications?

Is there a history of trauma or out-of-the-ordinary activity
recently?


Has the patient had recent eye surgery? (If so, immediately refer the
patient to the surgeon who performed the procedure.)

Does the patient wear contact lenses? If so, does the patient sleep in
the contacts; when were the contacts last changed, and has anything
recently changed regarding care of the lens?
Has the patient had a recent cold or upper respiratory tract infection?


Has the vision decreased?

Is there pain? If so, can the patient describe the pain?

Is there discharge from the involved eye(s)?

Is the eye itching?
Is there light sensitivity?
Do the symptoms change the environment?

How to Examine
Nine diagnostic steps are used to evaluate a patient with a red eye:
1. Determine whether the Visual acuity is normal or decreased, using a Snellen chart or
near card.
2. Decide by inspection what pattern of redness is present and whether it is due to
subconjunctival hemorrhage, conjunctival hyperemia, ciliary flush, or a combination
of these.
3. 3. Detect the presence of conjunctival discharge and categorize it as to amount—
profuse or scant—and character—purulent ,mucopurulent, or serous. .
Figure: Purulent conjunctivitis

With the eversion of the lower eyelid, a creamy white exudate
is visible highlighted by the conjunctival hyperemia
How to Examine ( cont.):

4. Detect opacities of the cornea including:
large keratic precipitates (inflammatory deposits on the corneal endothelium, ;
Keratic Precipitates Corneal edema Corneal Leukoma
5. Search for disruption of the corneal epithelium by staining the cornea

with fluorescein


6. Estimate the depth of the anterior chamber as normal or shallow; detect any
layered blood or pus, which would indicate either hyphema or hypopyon, respectively.
Figure: Corneal ulcer with hypopyon
7. Detect irregularity of the pupils and determine whether 1 pupil is larger than the
other. Observe the reactivity of the pupils to light determine whether one pupil is
more sluggish than the other is non reactive.

8. If an elevated IOP is suggested, as in angle-closure glaucoma, and

reliable tonometry is available, then measurement of IOP can help
confirm the diagnosis *
9. Detect the presence of proptosis, eyelid malfunction, or any

limitations of eye movement.


Classification of a red eye depends primarily on whether the condition is
acute or chronic.
CLASSIFICATION OF A RED EYE

ACUTE ( starting with days) CHRONIC ( present for a longer week)
ACUTE PAINFUL ACUTE, NONPAINFUL WITH IRRITATION WITHOUT IRRITATION
Corneal disorders Subconjunctival KCS Adnexal disease
hemorrhage
Scleral inflammations conjunctivitis Pterygium
Anterior chamber reactions


❑ ACUTE PAINFUL RED EYES
❖ Symptoms that have begun within days should be assessed primarily for the presence of pain.
❖ The painful , red eye, is an urgent situation and should be discussed with an Eye MD.
❖ Arriving to a diagnosis with an acute, painful red eye will rely on the provider assessing each of the anatomic
structures of the eye to determine the etiology, starting with the:
cornea
sclera
anterior chamber
posterior segment.

This usually include:
1. Corneal disorders
2. Scleral inflammations
3. Anterior chamber disorders


1. Corneal Disorders
▪ Disruption of the corneal epithelium results in significant pain for the patient.
▪ The disruption can occur due to trauma, causing corneal abrasion or foreign body injury, or due to bacterial or
viral infections.
▪ A patient with an abrasion or foreign body will usually give a history of trauma causing the pain.
▪ An infectious keratitis will usually occur in a cornea that has been compromised through contact lens use or a
previous ocular disease.
▪ A red eye associated with soft contact lenses can be due to poor fit or inadequate lens hygiene. Symptoms can
range from mild conjunctival or superficial corneal irritation to a more serious, vision- threatening infection of
the cornea


1. Corneal Disorders HERPES SIMPLEX KERATITIS
S/Sx: In the center of the cornea is an irregular dendritic
Corneal haze/ white in the area of the ulcer ( branchlike ) lesion of the corneal epithelium
Mattering ( mucous secretions in the eye)
Pain
Photophobia
▪ HERPES SIMPLEX KERATITIS

Potentially serious form of keratitis and can lead to corneal
ulceration or scarring.
Characteristic dendrites can often be seen in the corneal
epithelium

2. Scleral Inflammations SCLERITIS
The sclera is the “white of the eye” and can become infamed Usually localized lesion, associated with collagen
with or w/o associated autoimmune disease ( RA, granulomatosis vascular disorders and rheumatoid disorders
with polyangitis)
SCLERITIS - is an inflammation ( loc. or diffused ) of the

sclera
S/Sx:
Pain ( maybe severe)
Violaceous hue of the sclera ( ind. Systemic disease such as
collagen vascular disorder)

EPISCLERITIS
2. Scleral Inflammations -appears flat, involves more superficial tissue, and is
EPISLERITIS usually not associated with serious systemic disease.
➢ It is an inflammation ( often sectoral) of the episclera, the
vascular layer between the conjunctiva and sclera)
➢ Usually uncommon and has the following features:
✓ No disharge
✓ Not vision threatening
✓ Often tender over the inflamed area
➢ If recurrent, it may be associated with an underlying systemic
inflammatory disease.

❑ ACUTE PAINFUL RED EYE Acute Angle-Closure Glaucoma

3. Anterior Chamber Reactions The irregular corneal reflection and hazy cornea
▪ Acute painful redeye associated with anterior chamber suggest edema
Pupil is mid-dilated; the iris appears to be displaced
disorders can be categorized into acute glaucoma or acute
anteriorly with shallowing of the AC.
inflammation. These findings plus elevated IOP are dxc of AACG
ACUTE ANGLE-CLOSURE GLAUCOMA
➢ Is an uncommon form of glaucoma due to sudden and
complete occlusion of the anterior chamber angle by iris
tissue
➢ Note: The more common chronic open-angle glaucoma
usually does not cause redness of the eye
❑ ACUTE PAINFUL RED EYE

3. Anterior Chamber Reactions
IRITIS ( Iridocyclitis) Ciliary flush
Dilated deep conjunctival and episcleral vessels
➢ Is an inflammation of the iris alone or of iris and ciliary body, adjacent and circumferential to the corneal limbus
often manifested by ciliary flush Best seen in natural light

❑ ACUTE NON PAINFUL RED EYES

This is usually not associated with any inflammation of the globe.
Usually limited to the conjunctiva and is non urgent
This usually include:
1. Subconjunctival hemorrhage
2. Conjunctivitis

❑ ACUTE NON PAINFUL RED EYE

1. Subconjunctival hemorrhage
➢ Is an accumulation of blood in the potential space between Subconjunctival hemorrhage
the conjunctiva and the sclera.
➢ Rarely vision threatening unless associated with significant
ocular trauma.
➢ Patient may note some ocular irritation but should not
complain of significant pain.
➢ Vision should not be affected

❑ ACUTE NON PAINFUL RED EYE

2. Conjunctivitis
➢ Is hyperemia of the conjunctival vessels. Conjunctivitis *
➢ Causes fall into several categories:
✓ Bacterial
✓ Viral
✓ Allergic
✓ Chemical
✓ Mechanical ( eyelashes or FB)
➢ History should guide the physician to the correct diagnosis.
CHRONIC IRRITATED EYE:

➢ Usually non urgent
➢ Ocular irritation associated with a red eye can be due to any process
that disrupts a smooth tear film across the surface of the cornea.
➢ The surface of the conjunctiva should be examined for any source of
the irritation including FB
➢ The function of the meibomian glands should be assessed to determine
if an adequate lipid layer is being produced for the tear film.
➢ The surface of the conrea should be examined for evidence of
keratopathy using fluorescein.
➢ This include:
✓ Keratoconjuctivitis sicca ( KCS )
✓ Pterygium


1. Keraotocojunctivitis Sicca ( “ dry eye”)
➢ Is a disorder resulting from tear deficiency or dysfunction
➢ It causes:
✓ pain,
✓ blurred vision,
✓ light sensitivity ( photophobia)
✓ Ocular redness

2. Pterygium
➢ Is an abnormal growth consisting of a triangular fold of tissue
that advances progressively over the cornea, usually from the
nasal side.
➢ Usually not serious
➢ Associated with UV exposure
➢ Occurs more frequently in tropical climates.
➢ Surgical excision is indicated if:
✓ PTE starts to encroach on the visual axis
✓ Significant astigmatism
✓ Bothersome epiphora

CHRONIC RED EYE WITHOUT IRRITATION:

Usually due to congestive process that has resulted in decreased flow of blood in the veins that drain the orbit.
Adnexal disease
Affects the eyelids, lacrimal apparatus and orbit
Eyelid inflammation include :
✓ stye
✓ Blepharitis
Eyelid lesions:
✓ BCC
✓ SCC
Molluscum contagiosum
Disorders Associated with RRed Eye: Basic Information & How to Identify Disorders
Associated with Red Eyeed Eye
CHRONIC RED EYE WITHOUT IRRITATION:
Adnexal disease
Abnormal eyelid function ( in Bells palsy and TED) cause ocular exposure and corneal breakdown
and may present with a red eye.
▪ Lagophthalmos ( poor eyelid closure)
! seen in comatose pts.
! can result in exposure keratitis, corneal ulceration, and
blindness.
▪ Entropion
! An eyelid that turns in toward the eye with the lashes contacting the globe surface
! Can result in pain, photophobia, tearing, and redness of the eye
▪ Lacrcimal diseases that can cause a red eye include:
✓ Dacryocystitis
✓ canaliculitis

Basic Information & How to Identify Disorders Associated with Red Eye
SYMPTOMS OF THE RED EYE:

1. Blurred vision - indicates serious ocular disease.
2. Severe pain – may indicate keratitis, ulcer , iridocyclitis, scleritis or glaucoma
3. Photophobia – is an abnormal sensitivity to light that accompanies iridocyclitis, either alone or
secondary to corneal inflammation.
4. Colored halos – or rainbow-like fringes are seen around a point of light and are usually a symptom
of corneal edema
5. Exudation ( mattering) – typically due to conjunctival or eyelid inflammation
6. Itching – is an non specific symptom, usually indicate allergic conjunctivitis

SIGNS OF RED EYE:

1. Reduced visual acuity – suggest an inflamed or infected cornea, iridocylitis, or glaucoma
2. Ciliary flush – injection of the deep conjunctival and episcleral vessels surrounding the cornea
3. Conjunctival hyperemia – is an engorgement of the larger and more superficial conjunctival vessels.
4. Corneal opacification – may be detected by direct illumination with a penlight, or they may be seen
with a direct ophthalmoscope ( with a plus lens) outlined against the red fundus reflex. Several
types can occur:
✓ Keratic precipitates – cellular deposits on the corneal endothelium; from iritis or
iridocyclitis
✓ Diffuse Haze – characteristic of corneal edema ; seen in acute glaucoma
✓ Localized opacities – due to keratitis or ulcer

SIGNS OF RED EYE:

5. Corneal epithelia disruption – occurs in corneal inflammations and trauma ; can be detected
using fluorescein staining
6. Pupillary abnormalities – pupil in an eye with iridocyclitis typically is somewhat smaller than of
the other eye due to reflex spasm of the iris sphincter muscle.
The pupil is occasionally distorted by a posterior synechiae
NOTE :
posterior synechiae - inflammatory adhesions between the lens and the iris
Peripheral anterior synechiae(PAS) - inflammatory adhesions between iris and the peripheral
corneal endothelium
7. Shallow anterior chamber depth – suggest AACG
Note: AC depth can be estimated through side illumination with a penlight
Compare the ACD of the red eye with that of the other unaffected eye
SIGNS OF RED EYE:

8. Elevated IOP
-IOP is unaffected by common causes of red eye other than iridocyclitis (IOP often low) and
glaucoma ( IOP often elevated)
- IOP should be measured if angle closure glaucoma is suspected.
9. Proptosis
- Is a forward displacement of the globe
- May be accompanied by conjunctival hyperemia or limitation of eye movement
- Small amount of proptosis are detected most easily by tilting the chin over the maxillla at the
relative corneal position
Note:
sudden proptosis suggests serious orbital or cavernous sinus disease.
In children, orbital tumor or infection should be suspected.
Thyroid eye disease ! Most common cause of chronic proptosis
SIGNS OF RED EYE:

10. Discharge
Type of discharge may be an important clue to the cause
of a patient’s conjunctivitis:
Purulent or mucopurulent – bacterial
Serous ( watery, clear, or yellow-tinged) – viral cause
Scant, white , stringy discharge - allergic and KCS
11. Preauricular LN enlargement – a frequent sign of viral
conjunctivitis

ASSOCIATED SYSTEMIC DISORDERS:
A. URTI and fever

➢ Infection of the upper respiratory tract accompanied by fever
maybe associated with conjunctivitis, particularly when these
symptoms are due to adenovirus type 3 and type 7.
➢ Allergic conjunctivitis may be associated with the seasonal rhinitis
of hay fever.
B. Eryhthema multiforme
➢ Is an acute, immune-mediated condition characterized by the
appearance of distinctive target-like lesions of the skin.
➢ These are often accompanied by erosions or bullae involving the
oral genital, and/or ocular mucosae.
➢ Can result in severe conjunctivitis, irreversible conjunctival scarring,
and blindness

THANK YOU !
STAY SAFE EVERYONE!
CONJUNCTIVA
CONJUNCTIVA
CLINICAL EVALUATION
SYMPTOMS:
1. Non-specific ( lacrimation,
irritation,stinging, burning,
photophobia)
2. Pain and FB sensation ( corneal
involvment)
3. Itching ( hallmark of allergic conj)

CONJUNCTIVA
CLINICAL EVALUATION:
II. DISCHARGE
1. watery – Acute viral and
allergic
2. mucoid – vernal, KCS
3. purulent – acute severe
bacterial
4. mucopurulent – mild
bacteria ( chlamydia)

CONJUNCTIVA
III. Conjunctival reaction
a. conj injection
b. subconjunctival he
3. edema
4. scarring
5. follicular reaction
6. Papillary raction

CONJUNCTIVA
IV. Membranes
a. Pseudomembranes
b. True membranes
V. Lymphadenopathy
- mostly: Preauricular and submandibular
- main causes:
Viral ( adeno)
Chlamydial
GC
Parinaud
oculogladular syndrome

CONJUNCTIVA
LABORATORY INVESTIGATIONS:
Indications:
1. Severe purulent conjunctivitis
2. Follicular conjunctivitis
3. Conjunctival inflammation
4. Neonantal conjunctivitis

 
CONJUNCTIVA
SPECIFIC INVESTIGATIONS:
1. Cultures
2. Cytological investigation
3. Inoculation
4. Detection of viral o chlamydial
antigens
5. Impression cytology
6. Polymerase chain reaction (PCR)
CONJUNCTIVA:
Bacterial Infections
BACTERIAL CONJUNCTIVITIS
- common ; self-limiting
- Causative agent: S. epidermidis, S. aureus, S. pneumoniae, and H.
influenzae
- * Virulent organisms: N gonorrhea, s pyogenes, N meningitidis
- MOI: direct contact with infected secretions or from the organisms
colonizing the patient’s own nasal or sinus mucosa
- Clinical Features:
- SYMPTOMS: Acute redness, grittiness, burning and discharge
- SIGNS:
- Matting of eyelids in AM ( accumulation of discharge at night)
- Edematous and crusted lids
- Initially watery discharge then mucopurulent days after
- Forniceal injection
- Beefy-red tarsal conjunctiva

CONJUNCTIVA:
Bacterial Infection
1. ACUTE PURULENT
• Less than 3 weeks duration
• Self-limited infection of the conjunctiva that evokes an acute inflamatory response with purulent discharge
• MC pathogen:
✓ S. pneuominae – (+) moderate purulent discharge,edema and conj hges, occasional membranes; rarely with corneal
ulcerations
✓ S. aureus – may produce acute blepharoconjunctivitis; less purelent and less severe symptoms compared to s.
pneumoniae
✓ H. influenzae – seen in young children;
- sometimes seen in assoc with otitis media
• Diagnosis: GS and CS not usually necessary unless with:
• Compromised hosts ( neonates and immunocompromised hosts)
• Severe cases of purulent conjunctivitis ( to differentiate from hyperacute ! systemic tx!)
• Cases unresponsive to initial tx
• Tx: Empiric antibiotic ( polymixin, aminogylcosides, and fluoroquinolones)
• *H influenzae – Polyxmixin B- trimethprim

CONJUNCTIVA
Bacterial Infections
ACUTE PURULENT

 
CONJUNCTIVA:
Bacterial Infection
2. Gonococcal conjunctivitis
• Presents with SEVERE PURULENT conjunctivitis, massive exudation, severe chemosis, and If untreated,
corneal melting and perforation
• MOT: sexually transitted ( fr direct genital-eye , genital-hand-ocular)
• Maternal-neonate transmission during vaginal delivery
• MC pathogen:
✓ N. gonorrhea ( gram (-) diplococci)
• S/Sx: rapid progressio, , copious purulent discharge
May be assctd with palp preauricaular LAD and conj membranes
• Diagnosis:
Grows well on chocolate agar & Thayer- Martin media
• Tx:
Systemic Antibiotics ( ceftriaxone)
Topical antibiotics ( erythromycin, bacitracin, genta)

CONJUNCTIVA:
Bacterial Infection
Gonococcal conjunctivitis

 
CONJUNCTIVA:
Bacterial Infection
2. Gonococcal conjunctivitis
* Neonatal conjunctivitis
• S/Sx:
• Typically develop bil conj discharge for 3-5 days afer parturition.melting and perforation
• Serosanguinous discharge initially, then becomes copious purulent exudate days later
• Diagnosis:
Grows well on chocolate agar & Thayer- Martin media
• Tx:
Systemic Antibiotics ( ceftriaxone, quinolones)
Topical antibiotics ( erythromycin, bacitracin, genta)

CONJUNCTIVA:
Bacterial Infection
Neonatal gonorrheal
conjunctivitis

 
CONJUNCTIVA:
Bacterial Infection
• 3. Chlamydial conjunctivitis
• Pathogenesis: C trachomatis –an obligate intracellular bacterium
• Trachoma: serotypes A-C
• Adult and neonatal inclusion conjunctivitis: serotypes D-K
• Lymphogranuloma venereum: serotypes L1, L2 and L3
• Diagnosis:
• Giemsa
• Cell culture isolation
• PCR
• Clinical Presentation
• 1. Trachoma
• 2. adult inclusion conjunctivitis
• 3. neonatal chlamydial conjunctivitis

CONJUNCTIVA:
Bacterial Infection
• TRACHOMA
• Common in communities with poor hygiene and sanitation
• S/Sx: FB sensation, tearing, and mucopurulent discharge
• Severe follicular reaction in the superior
• Arlt line – linear scarring of the superior tarsus
• Herbert pits – limbal depressions from involution and necrosis of follicles
• Mgt: Topical or oral tertracycline & erythromyin
• Azithromycin

CONJUNCTIVA:
Bacterial Infection
Trachoma:
Arlt lines Herbert pits

 
CONJUNCTIVA:
Bacterial Infection
• Adult chlamydial conjunctivitis
• An STD often found in conjunction with chlamydial urethritis or cervicitis
• Onset is typically 1-2 weeks after inoculation.
• S/Sx:
• Follicular reaction
• Scant mucopurulent discharge
• Palpable preauricular LAD
• TX:
• Often resolves spontaenously in 6-18 months
• Recommended regimens:
• Azithromycin 1000 mg SD
• Doxycycline 100 mg BID x 7 days
• tetracycline 250 mg QID X 7days
• Erythomycin 500 mg QID for 7days

CONJUNCTIVA:
Bacterial Infection
Adult inclusion conjunctivitis

 
CONJUNCTIVA:
Bacterial Infection
• 4. Parinaud Oculoglandular Sydrome
• A granulomatous conjunctivitis with regional lymphadenopathy
• Caused by Cat-scratch disease ( CSD)
• Primary causative agent: Bartonella hanselae
• Other causative agents:
• Afipia felis
• Tularemia
• Tuberculosis
• Sporotrichosis
• Syphilis
• S/Sx:
• Unilateral granulomatous conjnctivitis in the tarsus, and conj sbout 3-10 days after inuculation
• Diagnosis:
• Detection of antibodies
• Tx: Undeterrmined ( azithro, erythro, or doxy)

CONJUNCTIVA:
Allergic Inflammations
• ALLERGIC CONJUNCTIVITIS
• Most common form of ocular and nasal allergy
• A hypersentivity reaction to specific-airborne antigens
• Classification:
• A. Seasonal allergic rhinoconjunctivitis – “ hay fever “ during summer
• B. Perennial allergic rhinoconjunctivitis – symptoms throughtout the year
• symptoms: transient acute attacks of redness, watering and itching
• Signs:
• lid edema
• Milky conjunctiva
• Small papillae
• Treatment:
• topical mast stabilizer ( ndeocromil) or antihistamines ( levocabastine)

CONJUNCTIVA:
• VERNAL KERATOCONJUNCTIVITIS
• Recurrent, bilateral ocular inflammation
• Primarily affecting boys
• IgE and cell mediated immune mechanism
• 2/3 have a history of atopy
• Patients often develop asthma and eczema in infancy
• Onset: after age of 5 years
• Seasonal ( peak over late spring and summer)
• Symptoms: intense ocular itching with tearing, photophobia, , FB
sensation and burning

CONJUNCTIVA:
• VERNAL KERATOCONJUNCTIVITIS
• Clinical features:
• A. Palpebral – diffuse papillae, which may enlarge to have a flat
topped appearance ( “ cobble stones”)
• B. Limbal – mucoid nodules around the limbus with discrete spots
( Trantas dots) -! composed of esosinophils
• Keratopathy
• Punctate epithelial erosions
• Shield ulcers
• plaque formations
• pseudogerontoxon

CONJUNCTIVA:
• Vernal Conjunctivitis

 
CONJUNCTIVA:
• ATOPIC CONJUNCTIVITIS
• Rare
• Typically affects young men with atopic dermatitis
• Ocular manifestations are similar, but not the same as, VKC
• Unlike VKC, which may resolve spontaneously, AKC persists for many years
• Clinical features:
• Lids are red, thickened and macerated (can be assctd with chronic staph
blephartis
• Conunctivitis ( mostly inferior fornix and tarsal conj)
• Keratopathy – erosions and ulcers
• Treatment:
• topical and or systemic mast stabilizer ( ndeocromil) or antihistamines
( levocabastine)
• NSAIDs
• Steriods
• Supratarsal steroid injections

Conjunctiva:
Blistering Mucocutaneous Diseases
I. Cicatricial pemphigoid
II. Steven-Johnson Syndrome

 

Conjunctiva:
An idiopathic, subepidermal/subepithelial blistering and scarring autoimmune ( type 2
hypersensitivity) disease
Characterized by autoantibodies that bind to basement membrane.
Usually presents in late middle age and affects women more commonly than men
Maybe associated with mucocutaneous lesions but may be isolated ( pure OCP)
Always BILATERAL , but frequently assymetrical
CLINICAL FEATURES:
non specific symptoms: irritation, burning and tearing
Signs:
papillary conj
Subconj bullae , ulcers, pseudomembranes
Subepthelial fibrosis
Progressive course interrupted by episodes of subacute inactivity (
diffuse conj hyperemia and edema)

Conjunctiva:
Complications:
Dry eye
Symblepharon
Ankyloblepharon
Secondary keratopathy
end-stage disease
keratinization of the corneal

surface

Conjunctiva:
Treatment:
A. Topical: steroids, artificial tears
B. Subconjunctival Mitomycin C
C. Saline contact lens
D. Systemic ( steroids, dapsone, cytotoxic agents)
E. Surgery

Conjunctiva:
I. Stevens–Johnson syndrome
- an acute, severe, mucocutaneous blistering disease, which primarilyoccurs in
healthy individuals.
- Males are affected more than females
- etiology unknown ( prob an abnormal immunological reaction)
- most common precipitating factor: HYPERSENSITIVITY to drugs and viral
infections.
- basic lesion: acute vasculitis ( skin and mucous membranes)
- self-limiting, most patients recover with goof function of affected tissues when
the acute phase is controlled

Conjunctiva:
- Clinical features:
Presentation: fever , malaise, sore throat,
possibly cough and arthralgia
( lasting for 14 days)
Signs:
Crusty eyelids
transient, self-limiting papillary
conjunctivitis ( MC feature)
Severe membranous or pseudomembranous
conjunctivitis

Conjunctiva:
Complications:
a. Symblepharon and keratinization
b. Epiphora
c. Dry Eye
d. Keratopathy
Treatment:
1. systemic steroids
2. Topical steroids
3. Scleral ring – to prevent symblepharon formation
4.other measures –use of topical retinoic acid for
keratinization, tear supplements, therapeutic CL,
punctal occlusion and surgery

Conjunctiva:
Other causes of red eye
PINGUECULA
- extremely common
- mostly bilateral and assymtomatic
- SIGNS:
yellow white spots on the bulbar conj
adjacent to nasal and temporal limbus
- Tx: usually unnecessary ( slow growth)
* if inflamed! anti-inflammatory

Conjunctiva:
PTERYGIUM:
- Triangular fibrovascular subepthelial ingrowth of
degenerative bulbar conjunctival tissue
over the limbus onto the cornea
- Tx: Artificial tears
Pterygium excision ( simple or with graft +/-
mitomycin C)

Conjunctiva:
CONJUNCTIVAL SQUAMOUS CELL CARCINOMA

- rare, slow-growing tumor of low-grade malignancy ( may arise
de novo or from pre-existing CCIN
- Usually in late adulthood
- Signs: (+)fleshy ,pink, papillomatous or gelatinous ass, often
associated with feeder vessels
- Lesions frequently juxtalimbal
- Tx: 1. surgical excision
- 2. Topical chemotherapy – MMC or 5-FU
- 3. Enucleation – if with invasion\
- 4.Exenteration for advanced cases with orbital involment

Conjunctiva:
CONJUNCTIVAL LYMPHOMA
- NOTE: lymphocytes normally reside in the substantia propria,
so the conj may be a seat of lymphoproliferative lesions that
constitute a spectrum ranging from :
Benign reactive hyperplasia ! atypical hyperplasia !
lymphoma
- presentation: late adulthood with irritation and painless
swelling
- Signs: slow-growing, mobile, salmon-pink or flesh-coloured
infiltrates in the inferior fornices or epibulbar surfaces which
may be bilateral.
* rarely, it may mimic chronic conjunctivitis

UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA

JONELTA FOUNDATION SCHOOL OF MEDICINE
VISION LOSS
Carmina M. Lim, MD, DPBO, MHA
VISION LOSS
VISION LOSS 
is the lost of ability to see clearly
ACUTE VISION LOSS

Questions to ask the patient in the wake of sudden vision loss include:
Is there any pain associated with the vision loss?
Is the vision loss transient, persistent, or progressive?
Is the vision loss monocular or binocular?
How severe is the loss of vision? Is all, or part, of the visual field affected?
What was the tempo? Did the vision loss occur abruptly, or did it develop over hours,
days or weeks?
When was normal vision last noted from the eye?
What is the patient’s age and medical condition?
Is there a history of previous ocular disease or surgery, including contact lens wear?
ACUTE VISION LOSS

Narrowing the Diagnosis From the History
1. Pain
2. Sudden recognition of vision loss
3. Previous Medical History
4. Previous ocular history
ACUTE VISION LOSS

1. Pain
❑ Pain in or around the eye is usually associated with inflammation that can be
infectious in etiology
❑ In general, most painful vision loss will be associated with relatively anterior
portions of the eye ( cornea , anterior chamber)
❑ Posterior ocular processes that produce painful vision loss:
✓ endophthalmitis
✓ Retrobulbar optic neuritis
ACUTE VISION LOSS

2. Sudden recognition of vision loss
❑ Some patients will have a chronic process causing vison loss that was not
recognized by the patient until the contralateral eye was covered.
❑ It is useful to determine the last time the patient could confidently say that good
vision was noted from the eye.
ACUTE VISION LOSS

3. Previous Medical History
❑ This would include:
✓DM
✓CVD
✓Autoimmune disease
✓HPN
ACUTE VISION LOSS

4. Previous ocular history
❑ Patient who have had known previous ocular condition and/ or surgeries are
more likely to have vision loss related to these previous conditions.
❑ Elicit hx of:
✓DM retinopathy
✓Glaucoma
✓Intraocular surgery
✓CL use
ACUTE VISION LOSS

HOW TO EXAMINE:
1. VA testing – first thing to be determined
2. Confrontational VF testing –normal VA does not assure that significant vision has not been
lost, because the entire VF, including peripheral vision must be considered.
3. Pupillary Reactions – useful in the evaluation of vision loss especially when that reaction is
asymmetric.
4. Red Reflex Evaluation and Ophthalmoscopy – dulling of the red reflex indicates a media
opacity, which could be decreased clarity of the cornea, or vitreous.
5. Penlight Examination – simple penlight may detect corneal disease responsible for acute
vision loss.
6. Tonometry – to detect angle closure attack
ACUTE VISION LOSS

HOW TO INTERPRET FINDINGS:
❑ Acute vision loss can be categorized into 3 groups:

1. Vision loss associated with pain
2. Vision loss not associated with pain, without a clear media
3. Vision loss not associated with pain, with a a clear media
ACUTE VISION LOSS

1. Vision loss associated with pain
A. Corneal Disease
B. Anterior segment Inflammation
C. Acute Glaucoma
ACUTE VISION LOSS

ACUTE VISION LOSS WITH PAIN
❖ Corneal disease
➢Acute vision loss due to cornea could be due to

✓Corneal abrasions
✓Infections
✓Corneal edema
✓Contact lens over –wear ( cornea can become “
starved of oxygen”
➢Tests performed : Fluorescein staining and slit lamp
exam
ACUTE VISION LOSS

❖ Glaucoma
➢ a sudden rise in IOP associated with acute glaucoma

will result in vision loss due to corneal edema
➢Pain is associated with elevated pressure in the eye, but
rather than true eye pains, patients will often have
referred pain in the forehead or brow.
➢Tests performed : slit lamp exam
tonometry
ACUTE VISION LOSS

❖ Segment Inflammation
➢due to :
✓ iritis/ iridocyclitis
➢ patients will avoid light due to the pain
associated with the movement of the iris.
➢Tests performed : slit lamp exam
ACUTE VISION LOSS

2. Vision loss associated without pain
➢Vision loss not associated with pain can be categorized depending on
whether the patient has a clear media or not
A. Painless Acute Vision Loss Without Clear Media
✓ Corneal Edema
✓ Hyphema
✓ Vitreous Hemorrhage
ACUTE VISION LOSS

2. Vision loss associated without pain
➢ Vision loss not associated with pain can be categorized depending on whether the patient has a clear media or not
A. Painless Acute Vision Loss with Clear Media
i. Retinal Disease
i. Macular Disease
✓ Retinal Detachment
✓ Retinal Vascular Occlusion
✓ CRAO
✓ CRVO
ii. Optic Nerve Disease
✓ Optic Neuritis
✓ Retrobulbar Optic Neuritis
✓ Papilltis and Papilledema
✓ Ischemic Optic Neuropathy
✓ Giant Cell Arteritis
iii. Trauma
ACUTE VISION LOSS

Painless Acute Vision Loss Without Clear Media
❖Corneal Edema
➢Recognized by dulling of the normally crisp reflection of
incident light off the cornea ( The cornea, crystal clear
when healthy, takes on a ground glass appearance)
➢Common causes:
✓Angle closure glaucoma
✓Corneal endothelial dysfunction
✓Iatrogenic ( post surgery) – more gradual onset
✓Acute corneal infection ( Herpes Simplex virus keratitis)
ACUTE VISION LOSS

❖Hyphema
➢Presence of blood in the anterior chamber
➢Any significant hyphema reduces vision.
➢Hyphema could be:
a. Direct consequence of blunt trauma to a normal eye
b. Spontaneous – due presence of abnormal iris vessels (
seen in tumors, DM, intraocular surgery, chronic
inflammation)
ACUTE VISION LOSS

❖Cataract
➢Most cataract develop slowly
➢Rare patients may interpret rapid progression of a cataract
as sudden vision loss
➢Sudden changes in blood sugar or serum can alter the
hydration of the lens.
ACUTE VISION LOSS

Painless Acute Vision Loss Without Clear
Media
❖Vitreous Hemorrhage
➢Large vitreous hemorrhage may
occur after trauma and in any
condition causing retinal
neovascularization (Proliferative
diabetic retinopathy,retinal
vascular occlusions,proliferative
sickle cell retinopathy) Figure: Vitreous hemorrhage seen in red reflex.
Ophthalmoscopic examination reveals a
darkened red reflex from the patient’s left eye
➢Diagnosis is confirmed with slit resulting from a vitreous hemorrhage
lamp exam through a dilated (Courtesy of Kellogg Eye Center , University of
Michigan.)
pupil.
ACUTE VISION LOSS

Painless Acute Vision Loss With Clear Media
Retinal detachment
➢Acute vision loss id a feature of an
extensive retinal detachment.
➢S/Sx: flashing of lights ( photophsia)
floaters
shade over the vision in 1 eye.
Figure: Retinal Detachment.
(+) RAPD ( if the detachment is A wide angle photograph of the
extensive enough to reduce the fundus reveals folds of retina
extending into the macula
visual acuity. inferotemporal to the disc.
In this photo, the focus is on the
➢Dx confirmed with ophthalmoscopy elevated retina which renders the disc
through a dilated pupil: retina appears slightly out of focus.
elevated , with folds and the choroidal
background is indistinct.
ACUTE VISION LOSS

Macular Disease
➢S/Sx: sudden vision loss
➢Metamorphopsia ( defect of central vision in which the
shapes of objects appear distorted) could be a sign
of bleeding from a neovascular net
➢Tx: Anti-VEGF injection
➢Laser Sx
ACUTE VISION LOSS

RETINAL VASCULAR OCCLUSION
➢ is a relatively common cause of
sudden vision loss and may be
transient and permanent.
➢Transient monocular vision loss is due to
arterial insufficiency
➢Could lead to: Figure: Cholesterol embolus in retinal
arteriole.
✓ CRAO In the most common sources of emboli
are fibrin and cholesterol from ulcerated
✓ BRAO plaques in the wall of the carotid artery.
✓ CRVO
❖Hollenhorst plaque  is a
cholesterol embolus that lodges at
an arterial bifurcation
ACUTE VISION LOSS

Central Retinal Artery Occlusion
➢ prolonged interruption of retinal arterial
blood flow causes permanent damage to
the ganglion cells and other tissue elements
➢ Manifested as sudden painless, and often
severe vision loss
➢ Fundus findings:
➢ narrowing of arterial blood columns with the
appearance of “boxcarring as rows of Figure: Central Retinal
corpuscles are separated by clear intervals” Artery Occlusion.
➢ Cherry-red spot ( due to pallor of the The retina is opaque,
perifoveal retina in contrast to the normal
color of the fovea except for the relatively
➢ Swelling of the optic disc ( when the thin area within the
ophthalmic or carotid artery proximal to the
origin of the central artery is occluded macula, producing the
cherry-red spot.
ACUTE VISION LOSS
Central Retinal Artery Occlusion
➢ When ophthalmoscopy reveals CRAO, immediate
treatment is warranted ( TRUE OPHTHALMIC EMERGENCY!:
restoration of blood flow may preserve vision if the
occlusion is only a few hours old.
➢ Tx:
✓ Eye compression
✓ Medications to lower the IOP
✓ Vasodilators
✓ Paracentesis of the anterior chamber
➢ Note: Most retinal artery occlusions are embolic in nature ,
central or branch retinal artery occlusion in an elderly
patient without a visible embolus should be evaluated for
GCA
ACUTE VISION LOSS
Branch Retinal Artery Occlusion
➢ when only a branch of the central
retinal artery is occluded , only a
sector of the retina opacifies,
producing only a partial loss of
vision.
➢More likely a result of an embolus
➢If visual acuity is affected , attempts
should be made to dislodge the Figure: Branch Retinal Artery Occlusion.
embolus by ocular massage. Inferotemporal branch retinal artery
occlusion
ACUTE VISION LOSS
Central Retinal Vein Occlusion
➢ Fundus findings :
✓ Disc swelling
✓ Venous engorgements
✓ Cotton wool ( small patches on the retina )
✓ Diffuse retinal hemorrhages
➢ Vision loss maybe severe ( subacute onset)
➢ Mostly encountered in older patients with:
✓ HPN
Figure: Central Retinal Vein
✓ Arteriosclerotic vascular disease Occlusion.
Dilated and tortuous veins, flame-
➢ Patients with CRVO needs a general medical evaluation
shaped hemorrhages, and cotton-
➢ Tx: laser. wool spots characterize this
condition. Sometimes this is
referred to as a “blood and
thunder” retinal appearance.
ACUTE VISION LOSS
OPTIC NERVE DISEASE
➢ inflammation of the optic nerve can often result in acute vision loss.
➢ON may appear normal initially, but pupillary responses are usually
abnormal in unilateral disease.
➢Includes:
✓ Optic neuritis
✓ Retrobulbar optic neuritis
✓ Papallitis and papilledema.
✓ Ischemic Optic neuropathy
✓ Giant cell arteritis
ACUTE VISION LOSS
Optic Neuritis
➢ inflammation of the optic nerve that is usually idiopathic (
maybe associated with multiple sclerosis)
➢S/Sx:
✓Reduced VA
✓RAPD
✓Color desaturation
✓Hyperemic and swollen discs
✓Tx: high-dose IV corticosteroids
ACUTE VISION LOSS
Retrobulbar Optic Neuritis
➢ usually seen in a young adult who’s experiencing a
monocular, stepwise, progressive loss of vision that has
developed over hours to days and is often accompanied by
pain on eye movement ( normal fundus findings)
➢S/Sx:
✓Reduced VA
✓RAPD
➢Dx: CT or MRI of the orbits and chiasmal region
ACUTE VISION LOSS
Papillitis and Papilledema
➢Papillitis  inflammation of the optic disc
➢Papilledema  swelling of the optic disc from increased ICP
➢S/Sx:
✓ reduced VA
✓ RAPD
✓ Fundus : blurred optic disc margins
✓ Obliterated optic disc cupping
➢Dx: CT or MRI of the orbits and chiasmal region
➢Spinal tap ( to document increased ICP like in idiopathic intracranial
hypertension)
ACUTE VISION LOSS
Papillitis and Papilledema
Papillitis Papilledema
▪ Inflammation of the optic disc ▪ Optic disc is elevated and the
margins are indistinct.
▪ Disc is swollen with blurred margins
▪ There is microvascular congestion
▪ Disc is hyperemic on the disc
▪ Usually unilateral ▪ Retinal veins are dilated
▪ If bilateral: could be differentiated ▪ Flame shaped hemorrhages are
from papilledema based on present
decreased VA in papillitis ▪ Appearance on the other eye
should be similar
ACUTE VISION LOSS

Ischemic Optic Neuropathy
➢ swelling of the disc accompanied by a
vision loss in an older adult is likely to
represent a vascular event rather than
an inflammation.
➢ S/Sx:
✓ Pale, swollen disc
Figure: Ischemic Optic
✓ Splinter hemorrhages Neuropathy.
✓ VA loss
✓ VF loss ( Altitudinal) Note for the presence of pale
➢ Emergent management is swelling of the optic disc, with
recommended to evaluate for possible associated flame-shaped
Giant Cell Arteritis
hemorrhages
ACUTE VISION LOSS

Giant Cell ( Temporal) Arteritis
➢ usually seen in patients over age of 60 who developed anterior ischemic optic neuropathy
➢ Predilection in medium-sized and large arteries ( superficial temporal, ophthalmic, posterior ciliary and proximal part
of the vertebral)
➢ Clinical presentation
➢ Sudden profound unilateral visual loss
✓ Temporal headache or tenderness ( pain while resting on a pillow)
✓ Scalp tenderness with hair brushing
✓ Ear or anterior neck discomfort ( carotidynia)
✓ Fatigue or pain in the tongue or jaw with chewing ( jaw claudication)
✓ Episode of transient diplopia or vision loss.
✓ Other complaints:
▪ Anorexia
▪ Weight loss www.slideserve.com
▪ General malaise
▪ Aching/fatigue of the upper arms or legs ( polymyalgia rheumatica)
ACUTE VISION LOSS

Giant Cell ( Temporal) Arteritis
➢Signs:
✓pale and swollen disc with small splinter-shaped haemorrhages
on its margin
➢ Dx:
✓ESR
✓C-reactive protein
✓Biopsy of the temporal artery
➢Tx: High-dose systemic corticosteroids ( for systemic arteritis)
ACUTE VISION LOSS

Traumatic Optic Neuropathy
➢ vision loss may be mild or severe and may recover spontaneously
➢is a condition in which acute injury to the optic nerve from direct or
indirect trauma results in vision loss.
➢Concussive head trauma shears the vascular supply to the optic
nerve, producing blindness
➢Typically , the optic nerve head and fundus looks are initially normal,
the only objective finding being a relative afferent pupillary defect.
➢Optic atrophy develop within 3-4 weeks post trauma.
✓Tx: Surgical decompression maybe undertaken in selected cases.
ACUTE VISION LOSS

VISUAL PATHWAY DISORDERS
a. Hemianopia
b. Cortical blindness
ACUTE VISION LOSS

Heminaopia
➢ homonymous hemianopia ( loss of vision on 1 side of both visual field)
➢ occlusion of the posterior cerebral arteries with infarction of the occipital lobe
➢ Dx: CT or MRI
ACUTE VISION LOSS

Cortical blindness
➢ extensive bilateral damage to the cerebral visual pathway resulting in complete loss of vision
(Cortical, central or cerebral blindness)
➢ Normally patients has a normal pupillary reactions
➢ Dx: CT or MRI
ACUTE VISION LOSS

FUNCTIONAL DISORDERS ( hysterical or malingering)
➢ vision loss without organic basis
➢ Examination produces results incompatible with organic blindness.
Acute discovery of chronic vision loss

➢A surprising number of cases of chronic vision loss turn up as acute
discoveries
Thank you!
CHRONIC VISION LOSS

CARMINA M. LIM, MD, DPBO, MMHoA
Chronic Vision Loss

1 2
3 4
Chronic Vision Loss

MAJOR CAUSES OF CHRONIC VISION LOSS IN ADULT
PATIENTS:
GLAUCOMA CATARACT
MACULAR DEGENERATION DIABETIC RETINOPATHY

Chronic Vision Loss

Vision loss has significant psychosocial, comorbid, and functional effects on
elderly people
Decrease in activity correlates with functional loss in activities of daily living (
ADL)
Can be age-related or secondary to an underlying pathological process
Chronic Vision Loss

Basic Information
▪ Overview
▪ When to Examine
▪ How to Examine
▪ How to Interpret the Findings
▪ Management of Referral
Chronic Vision Loss
GLAUCOMA
Chronic Vision Loss

I. GLAUCOMA
DEFINITION:
➢ Refers to a group of diseases that have in common a characteristic
optic neuropathy with associated visual function loss.
➢ Although elevated IOP is one of its primary factors , it’s presence or
absence does not have a role in the definition of the disease.
➢ Regardless of the IOP , the presence of glaucoma is defined as:
✓ Characteristic optic neuropathy consistent with excavation and
undermining of the neural and connective tissue elements of the
optic disc
✓ Development of the characteristic visual field
Chronic Vision Loss

I. GLAUCOMA
It is a significant cause of blindness and is the most frequent cause of

blindness among Africans Americans.
The incidence of glaucoma increases with advancing age and in patients
with a family history of glaucoma.
Majority of patients are asymptomatic
A significant amount of peripheral vision can be lost before the patient
notices visual disability.
Chronic Vision Loss

I. GLAUCOMA
▪ Usually insidious because symptoms and

noticeable visual field defects occur in
late stages of disease process.
▪ Visual field defects are characterized by

scotomas (areas of reduced or absent
vision of various shapes and contraction
of the peripheral field that usually spares
the central vision until late in disease
process ( “tunneling of vision”).
Chronic Vision Loss

I. GLAUCOMA
Detection of glaucoma in the early asymptomatic

stages usually requires special testing:
Chronic Vision Loss

I. GLAUCOMA
Detection of glaucoma in the early asymptomatic

stages usually requires special testing:
Optical coherence tomography

Optic nerve photography Visual field testing
CHRONIC VISION LOSS

I. GLAUCOMA
▪ Glaucoma is an optic neuropathy in which the intraocular pressure (IOP) is

an important risk factor.
▪ Prolonged elevation of IOP can lead to optic nerve damage; however, in
many cases, glaucomatous optic nerve changes are evident despite an
apparently “normal” pressure.
▪ Therefore, examination of the optic nerve is the most important way to
detect glaucoma in primary care setting.
Chronic Vision Loss

I. GLAUCOMA
OVERVIEW:
Intraocular Pressure:
Aqueous fluid ( prod. in the CB )

Flows through the pupil
Into the anterior chamber
Drained through the trabecular meshwork
Schlemm canal
Relative normal value ( statistical):

10-21 mmHg
Chronic Vision Loss

I. GLAUCOMA
OVERVIEW:
Intraocular Pressure
▪ It is largely dependent on the ease

of flow through the trabecular
meshwork and Schlemm Canal.
▪ The greater the resistance to

outflow, the higher the IOP.
Chronic Vision Loss

I. GLAUCOMA
OVERVIEW:
Aqueous humor dynamics
The aqueous humor flows out of the angle

of the anterior chamber through two
channels:
1. The trabecular meshwork ( 85%-90%)
2. Uveoscleral outflow ( 10-15%)
Chronic Vision Loss
I. GLAUCOMA
OVERVIEW:
Classification of Glaucoma
I. Primary glaucoma
➢ refers to glaucoma that is not associated with known ocular or systemic disease that caused
increased resistance to aqueous outflow or angle closure
II. Secondary glaucoma

➢ Are associated with ocular or systemic disorders responsible for decreased aqueous outflow.
Chronic Vision Loss
I. GLAUCOMA
OVERVIEW:
Types of Glaucoma
I. Open Angle Glaucoma
II. Close angle glaucoma

CHRONIC VISION LOSS

I. GLAUCOMA
When to Examine
▪ Ophthalmoscopy should be part of every comprehensive eye examination.

Particular attention should be given to patients are predisposed to glaucoma,
such as elderly individuals or those with a family history of glaucoma.
CHRONIC VISION LOSS

I. GLAUCOMA
When to Examine
▪ The American Academy of the Ophthalmology ( AAO) recommends a glaucoma

screening:
✓ every 2-4 years from age 40 to 54, with increasing frequency with age, as the
incidence of the disease increases with age.
▪ NOTE: Because African Americans and Hispanics have an even greater risk for
development of glaucoma:
✓ those between ages 20 and 39 should also be screened every 2-4 years, with
increasing frequency with age.
CHRONIC VISION LOSS Tonometry

I. GLAUCOMA
How to Examine
1. Tonometry
Direct Ophthalmoscopy
Goldmann – gold standard for
measurement
2. Direct phthalmoscopy
To assess the state of the disc
3. Gonioscopy
A special contact lens used to
Gonioscopy
examine the anterior chamber angle
structures
CHRONIC VISION LOSS

I. GLAUCOMA
How to Interpret the Findings
▪ The appearance of the optic disc can be described generally in terms of its colors
and of the size of its physiologic cup (a recognizable central depression within the
optic disc).
▪ The color of the optic nerve can be important in determining atrophy of the nerve
that is due to glaucoma or other causes.
▪ Temporal pallor of the optic nerve (Fig 3-5) can occur because of diseases that
damage the nerve fiber, such as brain tumors or optic nerve inflammation, or
conjunction with glaucomatous cupping.
CHRONIC VISION LOSS
I. GLAUCOMA
❑ TONOMETRY:
✓ Elevated if > 21mmHg
CHRONIC VISION LOSS

I. GLAUCOMA
❑ DIRECT OPHTALMOSCOPY:
✓ The increase in the cup is due to loss of nerve
fibers bundled in the optic nerve.
✓ The so-called cup-disc ratio is determined by
comparing the diameter of the cup that of the
disc (Fig 3-6).
✓ The optics disc generally should appear
symmetric between the eyes, and asymmetric,
cup-disc ratios should arouse suspicion of
glaucoma.
CHRONIC VISION LOSS

I. GLAUCOMA
✓ The larger the cup, greater the
probability of glaucomatous
optic nerve. A cup measuring
one-half the size of the disc or
larger-a cup-disc ratio of 0.5 or
more-raises suspicion of
glaucoma (Fig 3-7)
CHRONIC VISION LOSS

I. GLAUCOMA
✓ Disc hemorrhages are also a
possible sign of glaucoma
CHRONIC VISION LOSS

I. GLAUCOMA
✓ Vessel displacement
Chronic Vision Loss
CATARACT
Chronic Vision Loss

II. CATARACT
▪Cataract may occur as a congenital or genetic anomaly.

▪A cataract is any opacity discoloration of the lens, whether a small, local
opacity or the complete loss of transparency.
▪ The most common cause of cataract is age-related change.
▪Other causative factors include:

▪trauma,
▪inflammation,
▪metabolic and nutritional defects,
▪the effects of corticosteroids.
▪Cataract may develop very slowly over years or may progress rapidly,
depending on the cause and type of cataract.
Chronic Vision Loss

II. CATARACT
Symptoms of cataract
▪Patients may first notice image blur as the lens loses its
ability to resolve separate and distinct objects. Patients are
first aware of the disturbance of vision, then a diminution,
and finally a failure of vision.
▪Over time, cataracts may lead to a generalized

impairment of vision.
▪The degree of visual disability often varies depending on

lighting and task the patient needs to perform.
Chronic Vision Loss

II. CATARACT
When to Examine
▪ A patient with decreasing vision requires a complete examination to

determine the cause of the visual decline.
▪ If the lens is densely cataractous, ophthalmoscope will not provide a view of

the fundus through the opacity.
Chronic Vision Loss

II. CATARACT
How To Examine
The following examination method are helpful in obtaining an accurate
history of visual decline and determining whether vision loss in attribute to cataract,
to some other cause, or to a combination of causes.
1.Visual acuity testing

The first step in any evaluation of visual decrease is the measurement of visual
acuity..
2. Pupillary reaction testing
Even an advanced cataract would not produce a relative afferent pupillary
defect.
3. Slit-lamp examination
The examination at the slit lamp provides a magnified view of the lens, aiding in
the description of the type, severity, and location of the cataract.
4. Ophthalmoscopy
Funduscopic examination is required to evaluate the macula and optic
nerve for disease that could be contributing to the vision loss.
Chronic Vision Loss

II. CATARACT
▪An early cataract is not visible to the unaided

eye.
▪The lens can be evaluated with the
ophthalmoscope using a plus-lens setting.
Management or Referral
▪ The degree of visual disability should guide

the primary care provider in the
recommendation for treatment.
▪Referral for cataract evaluation is nonurgent.
Chronic Vision Loss
MACULAR DEGENERATION
Chronic Vision Loss

Macular Degeneration
Macular anatomy
❑The macula is situated between the temporal vascular
arcades.
❑The center of macula, the fovea, is an oval area situated
about 2 disc diameters temporal and slightly inferior to
the optic disc. (See Fig 1-17 for a depiction of the normal
fundus).
❑The macula is composed of both rods and cones and is
the area responsible for detailed, fine central vision.
❑The fovea (Fig 3-13) is partly avascular and appears
darker than the surrounding retina.
❑The foveola is the pit-like depression in the center of
macula. Here, there is a high density of cones but no rods
are present.
Chronic Vision Loss

Age-related macular changes

❑ Macular changes due to age include drusen, degenerative
changes in the retinal pigment epithelium, and choroidal
neovascular membranes.
❑ Drusen are hyaline nodules (or colloid bodies) deposited in
brunch’s membrane which seperates the retinal pigment
epithelium from the inner choroidal vessels.
❑ Degenerative changes in the retinal pigment epithelium itself
may occur with or without drusen.
Chronic Vision Loss

When to examine:
Any patient with decreasing vision requires examination to determine the
cause of the visual change.
Chronic Vision Loss

How to Examine
The following techniques are especially helpful in evaluating macular degeneration.
1. Visual acuity measurement
2. Amsler grid testing
Is a useful method of evaluating the function of the macula. Utilizing a patient’s best near correction, the test is
carried out by having the patient look with 1 eye at a time at a central spot on a page where horizontal and vertical parallel
lines make up a square grid pattern.
3. Ophthalmoscopy
The macular area is studied with the direct ophthalmoscope. Sometimes it is helpful to have
a patient look directly into the light of the instrument.
Chronic Vision Loss

Additional studies:
✓ stereoscopic slit-lamp examination
✓ fluorescein angiography
✓ Optical Coherence Tomography
Chronic Vision Loss

Management or Referral
A patient who has any of the following should be referred
urgently to an ophthalmologist:
✓ Recent onset of decreased visual acuity
✓ Recent onset of metamorphopsia (central vision
distortion)
✓ Recent onset of a scotoma (blind spot)
Chronic Vision Loss

The Visually Impaired Patient
✓ Despite medical or surgical therapy, some
patients with AMD will have a significant residual
visual impairment.
✓ These patients are candidates for low vision
services and should be referred to an
ophthalmologist capable of supplying these
services.
THANK YOU!

Red Eye, Conjuctivitis, Vision Loss

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Red Eye, Conjuctivitis, Vision Loss

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RED EYE AND VISION LOSS LONG

A major risk for the development of bacterial keratitis is

Contact lens wear

none of the above

What layer of the cornea regenerates rapidly following injury?

What are the features of anterior uveitis is

Contact lens wear

NONE OF THE ABOVE

Sudden persistent painless loss of vision

primary open angle glaucoma

central retinal vein occlusion +“

The effective treatment for Herpes Zoster ophthalmicus is

primary open angle glaucoma

Hollenhorst plaque seen in retinal vein occlusions is a:

none of the above

Purulent discharge can be seen in

dysfunctional tear syndrome

Visual acuity of 20/200

central retinal vein occlusion +“

central retinal artery occlusion

none of the above

fibrovascular overgrowth of the bulbar conjunctiva .~

Peripheral corneal synechia .~“

none of the above

Vision in a moderate to advanced case of glaucoma could be described as:

none of the above

Peripheral corneal endothelium

none of the above

The following may lead to the formation of pterygium EXCEPT:

exposure to ultraviolet rays

living in trapical area

frequent exposure to smoke

none of the above .~“

A hyperacute, hyperpurulent discharge is a clinical manifestation of

Prolonged use of topical ophthalmic anesthetics can cause?

cormeal damage ~~”

none of the above ~~“

The presence of symblepharon can be seen in

ocular cicatricial pemphigoid

Discharge seen in chlamydial conjunctivitis is normally described as:

none of the above

central retinal artery occlusion

‘Conjunctival squamous cell carcinoma

none of the above

conjunctival squamous papilloma

none of the above

none of the above

A branch-like lesion( dendritiform) in the cornea is secondary to?

None of the above

none of the above

Most frequent etiologic agent of conjunctivitis

Symptom of macular disorder

none of the above

All of the following can be caused by chlamydial infection EXCEPT:

herpes simplex keratoconjuntivitis

The color of the fluorescein staining in corneal ulcer is

defect of central vision in which the shapes of objects appear distorted

none of the above

Cherry-red spot is seen in:

central retinal artery oclusion .“

central retinal vein occlusion

none of the above