Eye Abnormality

Question 1

Eye examination

Answer 1

A. Look

1. Proptosis/ Ptosis
2. Squint
3. Unequal pupil size
4. Cataract, hazy cornea, Macrocornea
5. Bulbar conjunctival haemangioma

Examine:

1. Test vision roughly - distant and near and visual field
2. Extra-ocular eye muscle function
3. Do Fatiguability test ( >1 min vertical gaze)
4. Pupil’s reaction to light ? Squint after touch shining in front of eyes
5. Offer to look at Fundi and Corneal reflex

Listen for cranial bruit - AVM

Question 2

Eye changes in Dermatomyositis

Answer 2

1. Ptosis
2. Proptosis
3. Opthalmoplegia
4. Uveitis
5. Retinopathy and retinal haemorrhage

Question 3

Eye changes in Sturge Weber Syndrome

Answer 3

1. Telangiectasia
2. Buphthalmos (sign of infantile glaucoma)
3. Glaucoma
4. Haemangioma of iris/ choroid
5. Retinal vessel angioma
6. Retinal detachment
7. Fundi - dark red

Question 4

Unilateral Proptosis causes

Answer 4

Due to SOL in the orbit
1. Primary: Tumor in orbit (Gliomata, Retinoblastoma)
2. Secondary:
Tumor in the orbit - (Neuroblastoma; Leukaemia; Haematoma); Bone origin (Retrobulbar cellulitis; Osteomyelitis of maxilla); Vascular origin (Caverpis sinus thromboiss, AV malformation)

Question 5

Bilateral Proptosis causes

Answer 5

1. Exophthalmos in Thyrotoxicosis
2. Craniosynostosis (Crouzon; Aperts)
3. Neuroblastoma with metastasis to both orbits
4. Periorbital haematoma in fractured base of skull
5. Myopic eyes

Question 6

Steps in examination of proptosis

Answer 6

1. Confirm the presence of proptosis (Stand behind the patient and look from above)
2. Local examination (test Extraocular eye movements- note any peri-orbital inflammation/ haematoma; and test visual acuity; Ausculate for bruit; Offer to examine fundi
3. Examination of:
   a. Skull - ? Crouzon (examine the hands and note signs of ICP;
   b. Neck of goitre –> Signs of hypothyroidism;
   c. Evidence of malignancy—> Lymphadenopathy, hepato- splenomegaly, bleeding tendency and pallor, bone tenderness

Question 7

Aniridia ddx

Answer 7

1. AD
2. Iatrogenic - after cataract surgery
3. Associated with: Hemi-hypertrophy; Urogenital tract anomaly; Tumor - Wilm’s; adrenal and Rhabdomyosarcoma

Question 8

Microphthalmia ddx

Answer 8

1. Congenital rubella syndrome/ Toxoplasmosis
2. Fetal alcohol syndrome
3. Patau syndrome
4. Septo-optic dysplasia
5. Fanconi syndrome
6. Apparently small eye in Horner’s syndrome, ptosis and facial nerve palsy
7. Idiopathic

Question 9

Corneal opacity ddx

Answer 9

1. Unkown
2. Congenital - Rubella, herpes
3. Late onset - Down’s; Myotonic Dystrophy; DM
4. Early onset - Galactosaemia, LBW, Hurler’s
5. Scarring after trauma

Others:
Acute glaucoma

Systemic disease

1. Drugs e.g. Chloroquine, vit A
2. Metabolic causes - Hurler’s, cystinosis, uraemia

Question 10

Steps in clinical examination in corneal opacity

Answer 10

Local eye examination - assess degree of

1. Visual loss ( ?see object/ finger move/ light only)
2. Check light reflex
3. Note growth and mentality
4. Face- Dysmorphic features –Cushings’s/ Hurler’s
5. Skin rash
6. Hand - Abnormal crease (down’s), big thumb, no. of fingers, nail candida (DM)
7. CVS - murmurs (Down’s)
8. Abdo - Hepatosplenomegaly (Hurlers)

Question 11

Causes of Blue Sclera

Answer 11

1. Normal in infancy below 3 months
2. Infantile Glaucoma
3. Systemic diseases (Osteogenesis imperfecta; Ehler Danlos Syndrome; Rheumatoid arthritis; Marfan’s and Russel Silver syndrome)

Question 12

Heterochromia ddx

Answer 12

1. Waadenbury’s syndrome (white forelock, heterochromia+deafness)
2. Horner’s syndrome (present since birth) - lighter colour on the affected side)
3. Congenital Heterochromia (AD)
4. Eye diseases (Trauma, glaucoma, retinoblastoma, prosthesis)

Question 13

Large Pupil ddx

Answer 13

1. Aniridia
2. 3rd Nerve Palsy
3. Drugs- Local Atropine eyedrops, Systemic atropine, amphetamines, antihistamine, TCA OD.
4. After cataract extraction - pupil is irregular

Question 14

Pinpoint Pupil ddx

Answer 14

1. Horner’s syndrome
2. Drugs - Narcotics, cholinergic drugs, Organophosphorus toxicity, diazepam
3. Pontine haemorrhage

Question 15

Papilloedema ddx

Answer 15

A. Local causes:

1. Optic nerve diseases - Retrobulbar neuritis
2. Central retinal vein thrombosis
3. Tumor compression of optic nerve

B. Raised ICP

4. SOL in skull
5. Pseudotumor cerebri
6. Malignant hypertension

Question 16

Myopia (short sightness) ddx

Answer 16

1. Congenital
2. Puberty
3. Lens extraction
4. Marfan’s syndrome
5. Albinism