Will's眼科诊疗手册

Wall's

名等零四困运国

1.DIFFERENTIALDIAGNOSISOFOCULARSYMPTOMS

1.1Burning

More8mmonBlepharitis,dryeyesyndrome,conjunctivitis(dischargeoreyelidstickingadditionally).

Less8mmonCornealproblem(fluoresceinstainingofthecorneausually),inflamedpterygium/pinguecula,episcleritis,

superiorlimbickeratoconjunctivitis.

1.2CrossedEyesinChildren

SeeHEsodeviationsinChildren"(eyesturnedin),Section9.3,or"ExodeviationsinChildren"(eyesturnedout),Section9.4.

1.3DecreasedVision

/.Transientvisualloss(Visionreturnstonormalwithin24hours,usuallywithin1hour.)

More8mmonFewseconds(usuallybilateral):用pilledema.

Fewminutes:Amaurosisfugax(TIA)(unilateral),vertebrobasilararteryinsufficiency(bilateral).

10-60minutes:Migraine(withorwithoutasubsequentheadache).

Less8mmonImpendingcentralretinalveinocclusion,ischemicopticneuropathy,ocularischemicsyndrome(carotid

occlusivedisease),glaucoma,suddenchangeinbloodpressure,centralnervoussystem(CNS)lesion,opticdiscdrusen,

giantcellarteritis.

//.Visuallosslastinglongerthan24hours

A.Sudden,painlessloss

More8mmonRetinalarteryorveinocclusion,ischemicopticneuropathy,vitreoushemorrhage,retinaldetachment,optic

neuritis(usuallypainwitheyemovements).

Less8mmonOtherretinalorCNSdisease.

B.Gradual,painlessloss(overweeks,months,oryears)

More8mmonCataract,refractiveerror,open-angleglaucoma,chronicretinaldisease[e.g.,age-relatedmacular

degeneration(ARMD),diabeticretinopathy].

Less8mmonChroniccornealdisease(e.g.,cornealdystrophy),opticneuropathy/atrophy(e.g.,CNStumor).

C.F&infulloss:Acute-angleclosureglaucoma,opticneuritis(painwitheyemovements),uveitis,cornealhydrops

(keratoconus).

Note:Alwaysremembernonphysiologicvisualloss.

1.4Discharge

See"Redinthischapter.

1.5Distortion(ofVision)

More8mmonRefractiveerror,maculardisease(e.g.,centralserouschorioretinopathyorARMD),cornealirregularity.

Less8mmonCataract,topicaleyedrops(miotics),retinaldetachment,migraine(transient),CNSabnormality.

1.6DoubleVision

I.Monocular(Thedoublevisionremainswhentheuninvolvedeyeisoccluded.)

More8mmonRefractiveerror,cornealopacityorirregularity,cataract.

Less8mmonDislocatednaturallensorlensimplant,extrapupillaryopenings,maculardisease,retinaldetachment,

nonphysiologic.

II.Binocular(Thedoublevisioniseliminatedwheneithereyeisoccluded.)

A.Typicallyintermittent:Myastheniagravis,intermittentdecompensationofanexistingphoria.

B.Constant:Isolatedsixth-,third-,orfourth-nervepalsy;orbitaldisease(e.g.,thyroideyedisease,orbitalinflammatory

pseudotumor,tumor);cavernoussinus/superiororbitalfissuresyndrome;statuspostocularsurgery(e.g.,residual

anesthesia,displacedmuscle);statusposttrauma(e.g.,orbitalwallfracturewithextraocularmuscleentrapment,orbital

edema);internudearophthalmoplegia,vertebrobasilararteryinsufficiency,otherCNSlesions,spectacleproblem.

1.7DryEyes

SeeSection4.2.

1.8EyelidCrusting

MorecommonBlepharitis,meibomianitis,conjunctivitis.

Less8mmonCanaliculitis,nasolacrimalductobstruction,dacryocystitis.

1.9EyelidDroop

See"Ptosis"and"Pseudoptosis"inChapter2.

1.10EyelidSwelling

A.Associatedwithinflammation(usuallyerythematous)

More8mmonHordeolum,blepharitis,conjunctivitis,preseptalororbitalcellulitis,trauma,contactdermatitis.

LesscommonEctropion,cornealabnormality,urticaria/angioedema,insectbite,dacryoadenitis,erysipelas,eyelidorlacrimal

glandmass.

B.Noninflammatory:Chalazion;prolapseoforbitalfat(retropulsionoftheglobeincreasestheprolapse);laxityoftheeyelid

skin;cardiac,renal,orthyroiddisease;eyelidorlacrimalglandmass.

1.11EyelidTwitchFatigue

Lackofsleep,excesscaffeine,habit,cornealorconjunctivalirritation(especiallyfromaneyelashorcyst),dryeye,

blepharospasm(bilateral),hemifacialspasm,albinism(photosensitivity),aserumelectrolyteabnormalityoranemia(rarely).

1.12FlashesofLight

More8mmemRetinalbreakordetachment,posteriorvitreousdetachment,migraine,rapideyemovements(particularlyin

darkness).

Less8mmonCNS(particularlyoccipitallobe)disorders,retinitis.

1.13Floaters

See"SpotsinFrontofthe^es"inthischapter.

1.14Foreign-BodySensation

Dryeyesyndrome,blepharitis,conjunctivitis,trichiasis,cornealabnormality(e.g.,cornealabrasionorforeignbody,

recurrenterosion,superficialpunctatekeratitis),contactlens-relatedproblem,episcleritis,pterygiumorpinguecula.

1.15HalosAroundLights

Cataract,acute-angleclosureglaucomaorcornealedemafromanothercause(e.g.,cornealendothelialdystrophy,

aphakic/pseudophakicbullouskeratopathy),cornealhazinessormucus,drugs(e.g.,digitalis,chloroquine).

1.16Headache

SeeSection15.3.

1.171tchyEye

Conjunctivitis(especiallyviral,vernal,andallergic),blepharitis,dryeyesyndrome,topicaldrugallergyorcontactdermatitis,

giantpapillaryconjunctivitisoranothercontactlens-relatedproblem.

1.18LightSensitivity

See"Photophobia"inthischapter.

1.19NightBlindness

MorecommonRefractiveerror(especiallyundercorrectedmyopia),advancedglaucoma,smallpupil(especiallyfrommiotic

drops),retinitispigmentosa,congenitalstationarynightblindness,drugs(e.g.,phenothiazines,chloroquine,quinine).

Less8mmonVitaminAdeficiency,gyrateatrophy,choroideremia.

1.20Pain(Ocular)

A.Typicallymildtomoderate:Dryeyesyndrome,blepharitis,conjunctivitis,episcleritis,inflamedpingueculaorpterygium,

foreignbody(cornealorconjunctival),cornealdisorder(e.g.,superficialpunctatekeratitis),others.

B.Typicallymoderatetosevere:Cornealdisorder(abrasion,erosion,infiltrate/ulcer),anterioruveitis,scleritis,acute-angle

closureglaucoma.

1.21Photophobia

More8mmonCornealabnormality(e.g.,abrasion)oranterioruveitis.

Less8mmonConjunctivitis(mildphotophobia),posterioruveitis,albinism,totalcolorblindness,aniridia.

WithnormaleyeexaminationMigraine,meningitis,retrobulbaropticneuritis,subarachnoidhemorrhage,trigeminal

neuralgia,oralightlypigmentedeye.

1.22Proptosis

See"OrbitalDisease,"Section7.1.

1.23Ptosis

See"Ptosis"and"Pseudoptosis"inChapter2.

1.24RedEye

I.Dischargepresent

More8mmonConjunctivitis,ophthalmianeonatorumininfants,blepharitis.

Less8mmonAcuteallergicreaction,dacryocystitis,canaliculitis.

II.Nodischargepresent

A.F&inpresent:See"F^in"inthischapter.

B.Minimalornopainpresent

More8mmonSubconjunctivalhemorrhage,injectedpterygium/pinguecula,blepharitis,dryeyesyndrome.

Less8mmonConjunctivaltumor.

1.25SpotsinFrontoftheEyes

A.Transient:Migraine.

B.Ftermanentorlong-standing

More8mmonPosteriorvitreousdetachment,posterioruveitis,vitreoushemorrhage,vitreouscondensations/debris.

Less8mmonRetinaldetachment,cornealopacity.

Note:Somepatientsarereferringtoablindspotintheirvisualfieldcausedbyaretinal,opticnerve,orCNS

disorder.

1.26Tearing

I.Adults

A.F&inpresent:Cornealabnormality(e.g.,abrasion,foreignbody/rustring,recurrenterosion),anterioruveitis,eyelash

(trichiasis,entropion),cystorforeignbodyrubbingagainstthecornea,conjunctivalabnormality(e.g.,foreignbody,

laceration).

B.Minimalornopainpresent:Dryeyesyndrome,nasolacrimalductobstruction,punctalocclusionorotherteardrainage

abnormality,ectropion,conjunctivitis(especiallyallergicandtoxic),lacrimalsacmassorinflammation.

II.Children:Nasolacrimalductobstruction,congenitalglaucoma,cornealorconjunctivalforeignbodyorotherirritative

disorder.

1.27WateryEyes

See"Tearing"inthischapter.

1.28WhitePupil

See"Leukocoria,"Section9.1.

2.DIFFERENTIALDIAGNOSISOFOCULARSIGNS

2.1AnteriorChamber/AnteriorChamberAngle

BloodinSehlemm'sCanalonGonioscopy

Compressionofepiscleralvesselsbyagonioprism(iatrogenic),Sturge-Webersyndrome,arteriovenousfistula(e.g.,

carotid-cavernoussinusfistula),superiorvenacavaobstruction,hypotony.

Hyphema

Followingtraumaorintraocularsurgery,bleedingfromirisorcornealwoundneovascularization,herpessimplexorzoster

iritis,blooddyscrasiaorclottingdisorder(e.g.,hemophilia),intraoculartumor(e.g.,juvenilexanthogranuloma,

retinoblastoma,leukemia).

Hypopyon

Infectiouscornealulcer,endophthalmitis,severeiritis,reactiontoanintraocularlensorretainedlensproteinfollowing

cataractsurgery,intraoculartumornecrosis[e.g.,retinoblastoma(apseudohypopyon)],atightcontactlens.

2.2Cornea/ConjunctivalFindings

BandKeratopathy

SeeSection4.11.

CornealCrystals

Schnyder'scrystallinedystrophy,multiplemyeloma,cystinosis,gout,uremia,hypergammaglobulinemia,drugs(e.g.,

indomethacin,chloroquine),infectiouscrystallinekeratopathy.

CornealEdema

A.Congenital:Congenitalglaucoma,congenitalhereditaryendothelialdystrophy,posteriorpolymorphousdystrophy(PPMD),

birthtrauma(forcepsinjury).

B.Acquired:日rlypostoperative,aphakicorpseudophakicbullouskeratopathy,Fuchs'endothelialdystrophy,contactlens

overwear,trauma,acute-angleclosureglaucomaandothercausesofacuteelevationinintraocularpressure,corneal

hydrops(acutekeratoconus),herpessimplexorzosterkeratitis,iritis,failedcornealgraft,iridocornealendothelial(ICE)

syndrome,PPMD.

CornealFilaments

See"FilamentaryKeratopathy,"Section4.3.

DilatedEpiscleralVessels(intheAbsenceofOcularIrritationorPain)

Underlyinguvealmelanoma,arteriovenousfistula(e.g.,carotid-cavernousfistula),polycythemiavera,leukemia,ophthalmic

veinorcavernoussinusthrombosis.

EnlargedCornealNerves

MostimportantMultipleendocrineneoplasiatypelib(medullarycarcinomaofthethyroidgland,pheochromocytoma,

mucosalneuromas;mayhavemarfanoidhabitus).

OthersKieratoconus,keratitis,neurofibromatosis,Fuchs'endothelialdystrophy,Refsum'ssyndrome,trauma,congenital

glaucoma,failedcornealgraft,leprosy.

MembranousConjunctivitis

(Removalofthemembraneisdifficultandcausesbleeding).Streptococci;pneumococci;chemicalburn;ligneous

conjunctivitis;corynebacteriumdiphtheria;rarely,adenovirusorherpessimplexvirus.Seealso'*Pseudomembranous

Conjunctivitis"inthischapter.

OpacificationoftheCorneainInfancy

Congenitalglaucoma,birthtrauma(forcepsinjury),congenitalhereditaryendothelialorstromaldystrophy(bilateral),PPMD,

developmentalabnormalityoftheanteriorsegment(especiallyFteter'sanomaly),metabolicabnormalities(bilateral)(e.g.,

mucopolysaccharidoses,mucolipidoses),interstitialkeratitis,herpessimplexvirus,cornealulcer,cornealdermoid,

sclerocornea.

Pannus(SuperficialVascularInvasionoftheCornea)

Rosacea,tightcontactlensorcontactlensoverwear,phlyctenule,chlamydia(trachomaandinclusionconjunctivitis),

superiorlimbickeratoconjunctivitis(micropannusonly),staphylococcalhypersensitivity,vernalkeratoconjunctivitis,herpes

simplexvirus,chemicalburn,aniridia.

LargePapillaeontheSuperiorTarsus

Vernaloratopicconjunctivitis,giantpapillaryconjunctivitis,exposedsuture,prosthesis-inducedtrachoma,superiorlimbic

keratoconjunctivitis(finepapillae).

PigmentationoftheConjunctiva

Racialpigmentation(perilimbal),nevus,primaryacquiredmelanosis,melanoma,ocularandoculodermalmelanocytosis

(congenital,blue,episcleral,notconjunctival),Addison'sdisease,mascara,pregnancy,radiation,drug(e.g.,chlorpromazine)

ormetal(e.g.,argyrosisfromsilver).

PseudomembranousConjunctivitis

(Ftemovalofthemembraneiseasy,andnobleedingresults).Allofthecausesofmembranousconjunctivitis,aswellas

ocularcicatricialpemphigoid,Stevens-Johnsonsyndrome,superiorlimbickeratoconjunctivitis,gonococci,staphylococci,

chlamydiainnewborns,andothers.

Symblepharon[Fusionofthefyelid(Palpebral)ConjunctivawiththeConjunctivaCoveringtheGlobe(BulbarConjunctiva)]

Ocularcicatricialpemphigoid,Stevens-Johnsonsyndrome,chemicalburn,trauma,drugs,long-standinginflammation,

epidemickeratoconjunctivitis,atopicconjunctivitis,radiation.

Whorl-likeOpacityintheCorneal印ithelium

Amiodarone,chloroquine,Fabry'sdiseaseandcarrierstate,phenothiazines,indomethacin.

2.3EyelidAbnormalities

EyelidEdemaorSpelling

More8mmonOrbitalfatherniationfromaging,conjunctivitis,allergy,chalazion,orbitaldisease.

LesscommonCardiacdisease,renaldisease,urticaria/angioneuroticedema,dacryoadenitis,hypothyroidism,superiorvena

cavasyndrome.

fyelidLesion

See"MalignantTumorsoftheWelid,"Section6.11.

Pseudoptosis

Dermatochalasis(laxityoftheeyelidskinfromoldage),enophthalmos(e.g.,fromatraumaticblow-outfracture),phthisis

bulbi,microphthalmia(smalleye),chalazionorothereyelidtumor,eyelidedema,hypotropia(e.g.,indouble-elevatorpalsy).

Ptosis

More8mmonAging(e.g.,levatordehiscence),followingintraocularsurgeryortrauma,congenital.

Less8mmonMyastheniagravis,Horner'ssyndrome,third-nervepalsy,chronicprogressiveexternalophthalmoplegia,

cornealoranteriorsegmentdisease(e.g.,cornealabrasion),prolongeduseoftopicalsteroids,botulinumtoxinorsubtenons

steroidinjection.

2.4FundusFindings

BoneQjicules(WidespreadPigmentdumping)

MorecommonRetinitispigmentosaandassociatedsyndromes,disseminatedchorioretinitis(especiallyoldsyphilis),trauma,

pigmentarychangesofaging.

Less8mmonFollowingspontaneousreattachmentofaretinaldetachment(e.g.,toxemiaofpregnancy,Harada'sdisease),

Kearns-Sayresyndrome,abetalipoproteinemia,vitaminAdeficiency,viralinfections(e.g.,rubella),drugs(e.g.,thioridazine

andotherphenothiazines),retinopathyofprematurity(whenseenyearslaterasanadult),cystinosis,oldvascular

occlusions.

Bull's-EyeMacularLesion

Age-relatedmaculardegeneration(ARMD),Stargardt'sdisease,conedystrophy,chloroquineretinopathy,Spielmeyer-Vogt

syndrome.

ChoroidalFolds

Orbitalorchoroidaltumor,thyroidorbitopathy,orbitalinflammatorypseudotumor,posteriorsderitis,hypotony,retinal

detachment,markedhyperopia,sclerallaceration,papilledema.

ChoroidalNeovascularization(Gray-GreenMembraneorBloodSeenDeeptotheRetina)

More8mmonARMD,ocularhistoplasmosissyndrome,highmyopia,angioidstreaks,choroidalrupture(trauma).

Less8mmonDrusenoftheopticnervehead,tumors,followingretinallaserphotocoagulation,idiopathic.

Cotton-WoolSpots,withoutOtherAbnormalities(WhiteFluffyLesionswithFeatheredEdges,OftenObscuringRetinal

Vessels)

More8mmonAIDSretinopathy,hypertension,diabetes,collagen-vasculardisease(e.g.,systemiclupuserythematosus),

retinalartery/arterioleocclusion.

Less8mmonRetinalveinocclusion,cardiacvalvulardisease,carotidarteryobstruction,chesttrauma(Purtscher's

retinopathy),anemia,leukemia,lymphoma.

Embolus

See"AmaurosisFugax；'Section12.6;"BranchRetinalArteryOcclusion,"Section12.2;or"CentralRetinalArteryOcclusion/'

Section12.1.

Platelet-fibrin[Dullgrayandelongated(asopposedtoround):Carotiddisease.<sc>NOTE</sc>Similar-appearingfibrin

embolimayalsoarisefromtheheart.]

Cholesterol(Sparklingyellow,usuallyatanarterialbifurcation:Carotiddisease.)

Calcium(Dullwhite,typicallyaroundoronthedisc:Cardiacdisease.)

Cardiacmyxoma(Commoninyoungpatients,particularlyinthelefteye.Oftenoccludestheophthalmicorcentralretinal

arterybehindtheglobeandisnotseen.)

Talcandcornstarch(Smallyellow-whiteglisteningparticlesinmaculararterioles.Mayproduceperipheralretinal

neovascularization:IVdrugabuse.)

Lipidorair[Cotton-woolspots,notemboli,areoftenseen.Resultsfromchesttrauma(Purtscher'sretinopathy)andfracture

oflongbones.]

Others(Tumors,parasites,otherforeignbodies.)

MacularExudates

More8mmonDiabetes,choroidal(subretinal)neovascularmembrane,hypertension.

Less8mmonMacroaneurysm,Coats'disease(children),peripheralretinalcapillaryhemangioma,retinalveinocclusion,

papilledema,radiation.

NormalFundusinthePresenceofDecreasedVision

Retrobulbaropticneuritis,conedegenerations,Stargardt'sdisease/fundusflavimaculatus,otheropticneuropathy(e.g.,

tumor,alcohol/tobacco),rodmonochromatism,amblyopia,nonphysiologicvisualloss.

OptociHaryShuntVesselsontheDisc

Orbitalorintracranialtumor(especiallymeningioma),statuspostcentralretinalveinocclusion,chronicpapilledema(e.g.,

pseudotumorcerebri),chronicopen-angleglaucoma,opticnerveglioma.

RetinalNeovascularization

A.Fbsteriorpole:Diabetes,followingcentralretinalveinocclusion.

B.Fteripheral:Scklecellretinopathy,followingbranchretinalveinocclusion,diabetes,sarcoidosis,retinopathyof

prematurity,embolizationfromIVdrugabuse,chronicuveitis,others(e.g.,leukemia,anemia,Eales'disease).

Roth'sSpots(HemorrhageswithWhiteCenters)

MorecommonLeukemia,septicchorioretinitis(e.g.,secondarytosubacutebacterialendocarditis),diabetes.

Less8mmonFternidousanemia(andrarelyotherformsofanemia),sicklecelldisease,scurvy,systemiclupus

erythematosus,othercollagen-vasculardiseases.

SheathingofRetinalVeins(Periphlebitis)

More8mmonSyphilis,sarcoidosis,parsplanitis,sicklecelldisease.

LesscommonTuberculosis,multiplesclerosis,Eales'disease,viralretinitis(e.g.,HIVherpes),Behcet'sdisease,fungal

retinitis,septicemiaorbacteremia.

Tumor

See"MalignantMelanomaoftheChoroid,"Section8.3.

2.6Glaucoma

AcuteRiseinIntraocularPressure

Acute-angleclosureglaucoma,glaucomatocycliticcrisis(Fbsner-Schlossmansyndrome),inflammatoryopen-angle

glaucoma,malignantglaucoma,postoperativeglaucoma,suprachoroidalhemorrhage,retrobulbarhemorrhage.

2.7Iris

IrisHeterochromia(IridesofDifferentColors)

A.Involvedirisislighterthannormal:CongenitalHorner'ssyndrome,Fuchs'heterochromiciridocyclitis(most),chronic

uveitis,juvenilexanthogranuloma,metastaticcarcinoma,Waardenburg'ssyndrome(whiteforelock,decreasedhearing,

telecanthus).

B.Involvedirisisdarkerthannormal:Ocularmelanocytosisoroculodermalmelanocytosis,hemosiderosis,siderosis,

retainedintraocularforeignbody,ocularmalignantmelanoma,diffuseirisnevus,retinoblastoma,leukemia,lymphoma,ICE

syndrome,Fuchs'heterochromiciridocyclitis(some).

IrisLesion

A.Melanotic(brown):Nevus,melanoma,adenomaoradenocarcinomaoftheirispigmentepithelium.<sc>NOTE</soIn

heavilypigmentedirides,cysts,foreignbodies,neurofibromas,andotherlesionsmayappearpigmented.)

B.Amelanotic(white,yellow,ororange):Amelanoticmelanoma,inflammatorynoduleorgranuloma(sarcoidosis,

tuberculosis,leprosy,othergranulomatousdisease),neurofibroma,patchyhyperemiaofsyphilis,juvenilexanthogranuloma,

foreignbody,cyst,leiomyoma,seedingfromaposteriorsegmenttumor.

NeovascularizationoftheIris

Diabeticretinopathy,centralretinalveinorarteryocclusion,branchretinalveinocclusion,ocularischemicsyndrome(carotid

occlusivedisease),chronicuveitis,chronicretinaldetachment,intraoculartumor(e.g.,retinoblastoma),otherretinal

vasculardisease.

2.8Lens

IridescentLensParticles

Drugs,hypocalcemia,myotonicdystrophy,familial,idiopathic.

Lenticonus

A.Anterior(markedconvexityoftheanteriorlens):RuleoutAlport'ssyndrome(hereditarynephritis).

B.Fbsterior(markedconcavityoftheposteriorlenssurface):Usuallyidiopathic-maybeassociatedwithpersistent

hyperplasticprimaryvitreous.

2.9Neuro-ophthalmicAbnormalities

AfferentPupillaryDefect

A.Severe(2-3+):Opticnervedisease(e.g.,ischemicopticneuropathy,opticneuritis,tumor,glaucoma);centralretinal

arteryorveinocclusion;lesscommonly,alesionoftheopticchiasm/tract.

B.Mild(1+):Anyoftheabove,amblyopia,vitreoushemorrhage,maculardegeneration,branchretinalveinorartery

occlusion,retinaldetachment,orotherretinaldisease.

Anisocoria(PupilsofDifferentSzes)SeeSection11.1.

LimitationofOcularMotility

A.Withexophthalmosandresistancetoretropulsion:See"OrbitalDisease,"Section7.1.

B.Withoutexophthalmosandresistancetoretropulsion:Isolatedthird-,fourth-,orsixth-nervepalsy;multipleocularmotor

nervepalsies(see"CavernousSnus/SuperiorOrbitalFissureSyndrome,"Section11.8);myastheniagravis;chronic

progressiveexternalophthalmoplegia;orbitalblow-outfracturewithmuscleentrapment;ophthalmoplegicmigraine;

Duane'ssyndrome;otherCNSdisorders.

OpticDiscAtrophy

MorecommonGaucoma;statuspostcentralretinalveinorarteryocclusion;ischemicopticneuropathy;chronicoptic

neuritis;chronicpapilledema;compressionoftheopticnerve,chiasm,ortractbyatumororaneurysm;traumaticoptic

neuropathy.

LesscommonSyphilis,retinaldegeneration(e.g.,retinitispigmentosa),toxic/metabolicopticneuropathy,Leber'soptic

atrophy,Leber'scongenitalamaurosis,retinalstoragedisease(e.g.,Tay-Sachs),radiationneuropathy,otherformsof

congenitalorhereditaryopticatrophy(nystagmusalmostalwayspresentinthecongenitalforms).

OpticDiscSwelling(Edema)

See"F&pilledema,"Section11.12.

OptociliaryShuntVessels

See"FundusHndings"inthischapter.

ParadoxicalPupillaryReaction(PupilDilatesinLightandConstrictsinDarkness)

Congenitalstationarynightblindness,conedystrophy,opticneuritis,dominantopticatrophy.Rarely,amblyopiaand

strabismus.

2.10Orbit

ExtraocularMuscleThickeningonCTScan

More8mmonThyroidorbitopathy,orbitalinflammatorypseudotumor.

Less8mmonTumor(especiallylymphoma,metastasis,orspreadoflacrimalglandtumortomuscle),carotid-cavernous

fistula,cavernoushemangioma(usuallyappearsinthemuscleconewithoutmusclethickening),rhabdomyosarcoma

(children).

LacrimalGlandLesions

See"LacrimalGlandMass/ChronicDacryoadenitis,MSection7.7.

OpticNerveLesion(Isolated)

MorecommonOpticnerveglioma(especiallychildren),opticnervemeningioma(especiallyadults).

Less8mm0nMetastasis,leukemia,orbitalinflammatorypseudotumor,sarcoidosis,increasedintracranialpressurewith

secondaryopticnerveswelling.

OrbitalLesions/Proptosis

SeeHOrbitalDisease,"Section7.1.

2.11Pediatrics

Leukocoria(WhitePupillaryReflex)

SeeSection9.1.

NystagmusinInfancy

Congenitalnystagmus,albinism,Leber'scongenitalamaurosis,thalamicinjury,spasmusnutans,opticnerveorchiasmal

glioma,opticnervehypoplasia,congenitalcataracts,aniridia,congenitalcornealopacities.

2.12PostoperativeProblems

ShallowAnteriorChamber

A.Accompaniedbyincreasedintraocularpressure:Pupillaryblockglaucoma,suprachoroidalhemorrhage,malignant

glaucoma.

B.Accompaniedbydecreasedintraocularpressure:Woundleak,choroidaldetachment.

Hypotony

Woundleak,choroidaldetachment,cyclodialysiscleft,retinaldetachment,ciliarybodyshutdown,aqueoussuppression

causedbymedication.

2.13RefractiveProblems

ProgressiveHyperopia

Orbitaltumorpressingontheposteriorsurfaceoftheeye,serouselevationoftheretina(e.g.,centralserous

chorioretinopathy),posteriorscleritis,presbyopia,hypoglycemia,cataracts.

ProgressiveMyopia

High(pathologic)myopia,diabetes,cataract,useofmioticdrops,staphylomaandelongationoftheglobe,medications(e.g.,

sulfadrugs,tetracycline),childhood(physiologic).

2.14VisualFieldAbnormalities

AltitudinalFieldDefect

More8mmonIschemicopticneuropathy,hemibrancharteryorveinocclusion.

Less8mmonGlaucoma,opticnerveorchiasmallesion,opticnervecoloboma.

ArcuateScotoma

More8mmonGlaucoma.

Less8mmonIschemicopticneuropathy(especiallynonarteritic),opticdiscdrusen,highmyopia.

BinasalFieldDefect

More8mmonGaucoma,bitemporalretinaldisease(e.g.,retinitispigmentosa).

RareBilateraloccipitaldisease,tumororaneurysmcompressingbothopticnervesorchiasm.

BitemporalHemianopsia

More8mmonChiasmallesion(e.g.,pituitaryadenoma,meningioma,craniopharyngioma,aneurysm,glioma).

Less8mmonTiltedopticdiscs.

RareNasalretinitispigmentosa.

BlindSpotEnlargement

F&pilledema,glaucoma,opticnervedrusen,opticnervecoloboma,medullatednervefibersoffthedisc,drugs,myopicdisc

withacrescent,others.

CentralScotoma

Maculardisease;opticneuritis;ischemicopticneuropathy(moretypicallyproducesanaltitudinalfielddefect);opticatrophy

(e.g.,fromtumorcompressingthenerve,toxic/metabolicdisease);rarely,anoccipitalcortexlesion.

HomonymousHemianopsia

Optictractorlateralgeniculatebodylesion;temporal,parietal,oroccipitallobelesionofthebrain(strokeandtumormore

common;aneurysmandtraumalesscommon).Migrainemaycauseatransienthomonymoushemianopsia.

ConstrictionofthePeripheralFieldsLeavingOnlyaSmallResidua!

CentralField

Glaucoma;retinitispigmentosaorsomeotherperipheralretinaldisorder;chronicpapilledema;statuspostpanretinal

photocoagulation;centralretinalarteryocclusionwithcilioretinalarterysparing;bilateraloccipitallobeinfarctionwith

macularsparing;nonphysiologicvisualloss;carcinoma-associatedretinopathy;rarely,drugs.

2.15Vitreous

VitreousOpacities

Asteroidhyalosis;synchysisscintillans;vitreoushemorrhage;inflammatorycellsinvitritisorposterioruveitis;snowball

opacitiesofparsplanitisorsarcoidosis;normalvitreousstrandsfromage-relatedvitreousdegeneration;tumorcells;rarely,

amyloidosisorWhipple'sdisease.

3.TRAUMA

3.1CHEMICALBURN

TreatmentshouldbeinstitutedIMMEDIATELY,evenbeforemakingvisiontests.

Note:Thisincludesalkali(e.g.,lye,cements,plasters),acids,solvents,detergents,andirritants(e.g.,

mace).

EmergentTreatment

1.Copiousirrigationoftheeyes,preferablywithsalineorRinger'slactatedsolution,foratleast30minutes.However,if

nonsterilewateristheonlyliquidavailable,itshouldbeused.Donotuseacidicsolutionstoneutralizealkaliesorviceversa.

Itishelpfultoplaceaneyelidspeculumandtopicalanesthetic(e.g.,proparacaine)intheeyepriortoirrigation