Wills DDx of Ocular signs

Question 1

AC hyphema

Answer 1

V
I: iris neovascularization, herpes simplex/zoster iridocyclitis
T: traumatic
A: fuchs heterochromic iridocyclitis
M: blood dyscrasia or clotting disorder (e.g. hemophilia)
I: iatrogenic (intraocular surgery or laser), anticoagulation,
N: intraocular tumor (e.g. juvenile xanthogranuloma, RB, angioma)

Question 2

AC hypopyon

Answer 2

V
I: infectious cornea ulcer, endophthalmitis
severe iridocyclitis (e.g. HLA-B27 associated, Behcet disease), severe inflammatory reactions from a recurrent cornea erosion
T
A
M
I: reaction to an intraocular lens (sterile hypopyon), retained lens particle, device contaminant after cataract surgery (TASS), retained intraocular foreign body, drugs (e.g. rifampin)
tight contact lens
chronic cornea edema with ruptured bullae

N: intraocular tumor necrosis (e.g. psuedohypopyon from retinoblastoma)

Question 3

Blood in Schlemm Canal on Gonioscopy

Answer 3

compression of episcleral vessels by gonioprism (iatrogenic)
Sturge-Weber syndrome
AV fistula [e.g. carotid-cavernous sinus fistula (c-c fistula)]
SVC obstruction
hypotony

Question 4

Cornea/conjunctival findings
conjunctival swelling (chemosis)

Answer 4

allergy
any ocular/periocular inflammation
post-operative
drugs
venous congestion (e.g. c-c fistula)
angioneurotic edema
myxedema

Question 5

conjunctival dryness (xerosis)

Answer 5

V
I: Sjogren syndrome
post-cicatricial conjunctivitis, chronic dacryoadenitis

T
A: S-J syndrome, OCP
M: vitamin A deficiency
I: exposure (e.g. lagophthalmos, absent blink reflex, proptosis), radiation
N

Question 6

Cornea edema (congenital)

Answer 6

congenital glaucoma
CHED (AR is present at birth, AD form later onset)
PPMD
birth trauma (forceps injury)

Question 7

Cornea edema (acquired)

Answer 7

V
I: HSV or zoster keratitis, iritis
T: traumatic, exposure, chemical injuries
A
M: fuchs endothelial dystrophy
iridocorneal endothelial (ICE) syndrome
PPMD
I: post-operative edema, aphakic or PBK
failed corneal graft
CL overwear
acute increase in intraocular pressure (e.g. angle-closure glaucoma)
cornea hydrops (decompensated keratoconus)

N

Question 8

cornea edema -dilated episcleral vessels (w/o ocular irritation or paiN)

Answer 8

underlying uveal neoplasm
AV fistula (c-c fistula)
polycynthemai vera
leukemia
ophthalmic vein or cavernous sinus thrombosis
extravascular blockage of ophthalmic/orbital venous outflow

Question 9

Enlarged cornea nerves: most important

Answer 9

MEN2b (medullary carcinoma of the thyroid gland, pheochromocytoma, mucosal neuromas; may have marfanoid habitus)

Question 10

Enlarged cornea nerves: others

Answer 10

acanthamoeba keratitis
chronic keratitis
keratoconus
neurofibromatosis
fuchs endothelial dystrophy
refsum syndrome
trauma
congenital glaucoma
failed cornea graft
leprosy
ichthyosis
idiopathic
normal variant

Question 11

Membranous conjunctivitis: difficult removal of membrane with bleeding (membrane = coagulated exudate adherent to conjunctival epithelium)

Answer 11

adenovirus
streptococci pneuomococci
ligneous conjunctivitis
cornyebacterium diptheriae

chemical burn
HSV
ocular vaccinia

Question 12

pseudomembranous conjunctivitis: easy removal without bleeding

Answer 12

OCP
S-J syndrome
Superior limbic keratoconjunctivitis
gonococci
staphylococci
chlamydia in newborns
others

Question 13

cornea opacification in infancy

Answer 13

congenital glaucoma
birth trauma (forceps injury)
CHED or stromal dystrophy (OU)
PPMD
developmental abnormalitiy of the anterior segment (e.g. Peters anomaly)
metabolic abnormalities (bilateral - e.g. mucopolysaccharidoses, mucolipidoses)
interstitial keratitis
HSV
cornea ulcer
cornea dermoid
sclerocornea

Question 14

pannus (superficial vascular invasion of the cornea)

Answer 14

ocular rosacea
tight CL or CL overwear
phylectenule
chlamydia (trachoma and inclusion conjunctivitis)
superior limbic keratoconjunctivitis
HSV/HZV
chemical burn
OCP
aniridia
molluscum contagiousm
leprosy

Question 15

Pigmentation/discoloration of the conjunctiva

Answer 15

racial melanosis (perilimbal)
nevus
primary acquired melanosis
melanoma
ocular and oculodermal mealnocytosis (congenital, blue-gray, not conjunctival but episcleral)
Addison disease
pregnancy
radiation
jaundice
resolving SCH
mascara
conjunctival/subconjunctival foreign body
pharmacologic (chlorpromazine, topical epinephrine)

Question 16

Symblepharon (fusion of the palpebral conjunctiva with the bulbar conjunctiva)

Answer 16

OCP
S-J syndrome
chemical burn
trauma
drugs
long-standing conjunctival or episcleral inflammation
EKC
atopic conjunctivitis
radiation
congenital 
iatrogenic (post-surgical)

Question 17

whorl-like opacity in the corneal epithelium (verticillata)

Answer 17

amiodarone
chloroquine
fabry disease and carrier state
phenothaizines
indomethacin

Question 18

bull’s eye macular lesion

Answer 18

AMD
stargardt dz or fundus falvimaculatus
albinism
cone dystrophy
chloroquine or hydroxychloroquine retinopathy
Spielmeyer - Vogt syndrome (Batten)
central areolar choroidal dystrophy

Question 19

Choroidal folds

Answer 19

orbital or choroidal tumor
idiopathic orbital inflammatory syndrome
thyroid eye disease
posterior scleritis
hypotony
RD
marked hyperopia
scleral laceration
papilledema
post-operative

Question 20

CNV (gray-green membrane or blood seen deep to the retina) - MC

Answer 20

AMD
ocular histoplasmosis syndrome
high myopia
idiopathic polypoidal choroidal vasculopathy
angioid streaks
choroidal rupture (trauma)

Question 21

CNV (gray-green membrane or blood seen deep to the retina) - LC

Answer 21

drusen of the optic nerve head
tumors
retinal scarring s/p laser photocoagulation
idiopathic

Question 22

Embolus

Answer 22

platelet-fibrin (dull gray and elongated): carotid dz, less common cardiac
Cholesterol (sparkling yellow, usually at an arterial bifurcation): carotid dz
Calcium (dull white, typically around or on the disc): carotid dz
Cardiac myxoma (rare cardiac tumor, common in young pts, particularly in OS; often occludes the ophthalmic or central retinal artery behind the globe and is not seen)
talc/cornstarch (small yellow-white glistening particles in macular arterioles; may produce peripheral retinal NV: IVDA

Lipid or air (CWS not emboli are often seen): 2/2 chest trauma [purtscher retinopathy] and fracture of long bones

Others (tumors, parasites, other FB)

Question 23

Macular exudates - MC

Answer 23

DM, CVNM (subretinal), HTN

Question 24

Macular exudates - LC

Answer 24

Macroaneurysm, Coats dz (children), peripheral retinal capillary hemangioma, RVO, papilledema, radiation retinopathy

Question 25

Normal DFE in the presence of decreased vision

Answer 25

retrobulbar optic neuritis other optic neuropathy (e.g. Leber hereditary optic neuropathy, tumor, alcohol or tobacco) cone degeneration stargardt disease or fundus flavimaculatus rod monochromatism amblyopia nonphysiologic visual loss

Question 26

Optociliary shunt vessels on the disc

Answer 26

Vascular: prior CRVO ``` chronic papilledema (e.g. pseudotumor cerebri) chronic open-angle glaucoma ``` Neoplastic: orbital or intracranial tumor (especially meningioma) ON glioma

Question 27

Retinal NVE (posterior pole)

Answer 27

DM, s/p CRVO

Question 28

Retinal NVE (peripheral)

Answer 28

Vascular: s/p BRVO Infectious/inflammatory: syphilis, pars planitis, chronic uveitis Autoimmune: sarcoidosis, Metabolic: DM Iatrogenic/Idiopathic/genetic: sickle cell, coats dz, ROP, Others (leukemia, anemia, Eales, FEVR)

Question 29

Retinal NVE (retina hemorrhages with white centers) - MC

Answer 29

DM, leukemia, septic chroioretinitis (2/2 to bacterial endocarditis)

Question 30

Retinal NVE (retina hemorrhages with white centers) -LC

Answer 30

pernicious anemia (and rarely other forms of anemia) sickle-cell dz scurvy lupus and other connective tissue disease

Question 31

Sheathing of retina vessels (periphlebitis) - MC

Answer 31

syphilis sarcoidosis pars planitis sickle cell disease

Question 32

Sheathing of retina vessels (periphlebitis) - LC

Answer 32

``` V I: TB, MS; viral retinitis (HIV, herpes); fungal retinitis, bacteremia T A: Behcet's M I N ```

Question 33

Acute increase in IOP

Answer 33

``` V: suprachoroidal hemorrhage, hyphema, c-c fistula, retrobulbar hemorrhage I: inflammatory OAG, T A M I: acute angle-closure glaucoma, glaucomatocycltic crisis (Posner-Schlossman syndrome) malignant glaucoma post-operative N: other orbital dz ```

Question 34

Decreased IOP (hypotony)

Answer 34

``` V: ocular ischemia I: irdiocyclitis T: ruptured globe, cyclodialysis cleft, traumatic ciliary body shut-down. A M: I: phthisis bulbi, retinal/choroidal detachment severe dehydration drugs (e.g. glaucoma medications) post-operative N ```

Question 35

Iris heterochromia (involved iris is lighter than normal)

Answer 35

V I: Fuchs heterochromic iridocyclitis, chronic uveitis T A M: congenital Horner syndrome, Waardenburg syndrome I N: metastatic carcinoma

Question 36

Iris heterochromia (involved iris is darker than normal)

Answer 36

V I: Fuchs heterochromic iridocyclitis (depends on blue/brown eye) T: retained IOFB A M: hemosiderosis, siderosis, ICE, ocular melanocytosis or oculodermal melanocytosis I N: ocular malignant melanoma, diffuse iris nevus, RB, leukemia, lymphoma

Question 37

Spontaneous hyphema in child Ddx?

Answer 37

``` JXG Retinoblastoma ROP PFV Coat’s disease Herpes simplex uveitis ```

Question 38

Iris lesion - melanotic (brown)

Answer 38

nevus, melanoma, adenoma, or adenocarcinom of the iris pigment epithelium

Question 39

Iris lesion - amelanotic (white, yellow, orange)

Answer 39

``` V I: inflammatory nodule or granuloma (sarcoidosis, TB, leprosy, other granulomatous dz), neurofibroma patchy hypermia of syphilis T A M I: foreign body N: amelanotic melanoma, juvenile xanthogranuloma, cyst, leiomyoma, seeding from posterior segment tumor ```

Question 40

NVI

Answer 40

``` V: ocular ischemic syndrome, s/p vein/artery occlusion, other vascular dz I: chronic uveitis T A M: DM I: chronic RD N: intraocular tumor (melanoma, RB) ```

Question 41

iridescent lens particles

Answer 41

``` drugs hypocalcemia myotonic dystrophy hypothyroidism familial idiopathic ```

Question 42

Lenticonus anterior (marked convexity of the anterior lens)

Answer 42

Alport syndrome (hereditary nephritis)

Question 43

Lenticonus posterior (marked convexity of the posterior lens)

Answer 43

usually idiopathic, may be associated with persistent fetal vasculature

Question 44

APD - severe 2+ to 3+

Answer 44

optic nerve disease (e.g. ischemic optic neuropathy, optic neuritis, tumor, glaucoma) CRAO or CRVO less commonly - lesion of optic chiasm/tract

Question 45

APD - mild 1+

Answer 45

``` any of the preceding, amblyopia dense vitreous hemorrhage advanced AMD BRVO or BRAO RD or other retinal disease ```

Question 46

limitation of ocular motility without exophthalmos and resistance to retropulsion

Answer 46

V: multiple ocular motor nerve palsies (such as cavernous sinus syndrome) I T: orbital blow-out fracture with muscle entrapment A: CPEO and associated syndromes, myasthenia gravis M: Duane syndrome I: other CNS disorder, ophthalmoplegic migraine isolated CN3, 4, 6 palsy N

Question 47

optic disc atrophy - MC

Answer 47

V: s/p CRVO/CRAO, prior ischemic optic neuropathy I: chronic optic neuritis T: prior traumatic optic neuropathy A M I: chronic optic neuritis/papilledema, glaucoma, N: compression of optic nerve/chiasm/tract 2/2 tumor/aneurysm

Question 48

optic disc atrophy - LC

Answer 48

``` V I: syphilis T A M: retinal degeneration (RP), toxic or metabolic optic neuropathy, Leber hereditary optic atrophy, Leber cogenital amaurosis, lysosomal storage dz (Tay Sachs) other forms of congenital or hereditary optic atrophy (nystagmus almost always present in congenital forms) I: radiation neuropathy N ```

Question 49

Paradoxical Pupillary Reaction (Pupil Dilates in Light and Constricts in Darkness)

Answer 49

``` "BARADOXICAL" Best's Achromatopsia RP Albinism Dominant Optic nerve atrophy ON hypoplasia XI CSNB Amblyopia (rare) Leber's congenital amaurosis ```

Question 50

EOM thickening on imaging - MC

Answer 50

``` Thyroid orbitopathy (often spares tendon) Idiopathic Orbital Inflammatory Syndrome ```

Question 51

EOM thickening on imaging - LC

Answer 51

``` V: c-c fistula, SO vein thrombosis I T A M I N: Tumor (e.g. lymphoma, metastasis, or spread of lacrimal gland tumor to muscle) cavernous hemangioma (usually appears IN the muscle cone without muscle thickening) rhabdomyosarcoma (children) ```

Question 52

ON Lesion (isolated) - MC

Answer 52

optic nerve glioma (esp children) | optic nerve meningioma (esp adults)

Question 53

ON Lesion (isolated) - LC

Answer 53

``` metastasis leukemia idiopathic orbital inflammatory syndrome sarcoidosis increased ICP with 2ndary optic nerve swelling ```

Question 54

Nystagmus in infancy

Answer 54

``` V I T: CNS (thalmic) injury A M: congenital nystagmus, albinism I: Leber congenital amaurosis, spasmus nutans, ON hypoplasia, congenital cataracts, aniridia, congenital corneal opacities N: ON or chiasmal glioma ```

Question 55

Shallow AC - accompanied by increased intraocular pressure

Answer 55

pupillary block glaucoma suprachoroidal hemorrhage malignant glaucoma

Question 56

Shallow AC - accompanied by decreased intraocular pressure

Answer 56

wound leak choroidal detachment over filtration s/p glaucoma filtering procedure

Question 57

Hypotony

Answer 57

wound leak, choroidal detachment, RD, cyclodialysis cleft, ciliary body shutdown, pharmacologic aqueous suppresion

Question 58

Progressive hyperopia

Answer 58

V I: posterior scleritis, Serous elevation of the retina (CSR) T A M: hypoglycemia I: presbyopia, cataracts, s/p RK or other refractive N: orbital tumor pressing on the posterior surface of the eye

Question 59

Progressive myopia

Answer 59

``` V I T A M: DM I: high (pathologic) myopia, cataract, staphyloma and other elongation of the globe, K ectasia, medications (miotics, sulfa drugs, tetracycline),childhood (physiologic) N ```

Question 60

Altitudinal Field Defect - MC

Answer 60

ischemic optic neuropathy, hemi or branch retinal artery or vein occlusion, optic neuritis

Question 61

Altitudinal Field Defect - LC

Answer 61

glaucoma, ON or chiasmal lesion, ON coloboma

Question 62

Arcuate Scotoma - MC

Answer 62

glaucoma

Question 63

Arcuate Scotoma - LC

Answer 63

ischemic optic neuropathy (esp nonarteritic), optic disc drusen, high myopia, optic neuritis

Question 64

binasal field defect - MC

Answer 64

glaucoma, bitemporal retinal disease (e.g. RP)

Question 65

binasal field defect - rare

Answer 65

bilateral occipital disease, tumor or aneurysm compressing both optic nerves or chiasm

Question 66

bitemporal hemianopsia - MC

Answer 66

chiasmal lesion (e.g. pituitary adenoma, meningioma, craniopharyngioma, aneurysm, glioma)

Question 67

bitemporal hemianopsia - LC

Answer 67

tilted optic discs (LC) and rare (nasal RP)

Question 68

Blind spot enlargement

Answer 68

V I: MEWDS, acute idiopathic blind spot enlargement syndrome (may be on spectrum with MEWDS) T A M I: papilledema, glaucoma, optic nerve drusen, ON colobma, myelinated (medullated) nerve fibers off the disc, myopic disc with crescent, drugs N

Question 69

Central scotoma

Answer 69

V: ischemic optic neuropathy (more typically produces an altiduinal field defect) I T A M I: optic neuritis, macular disease N: optic atrophy (e.g. tumor compressing the nerve, toxic or metabolic disease), rarely an occipital cortex lesion

Question 70

constriction of the peripheral fields leaving a small residual central field (tunnel vision)

Answer 70

V: s/p PRP or cryotherapy, CRAO with cilioretinal artery sparing, bilateral occiptal lobe infarcation with macular sparing I: rarely medications (e.g. phenothiazines), vitamin A deficiency T A: autoimmune-associated retinopathy, M: RP or other peripheral retinal disorders (gyrate atrophy) I: chronic papilledema, nonphysiologic visual loss, glaucoma N: carcinoma, melanoma

Question 71

homonymous hemianopsia

Answer 71

V: temporal, parietal, or occiptal lobe lesion of the brain (MC: stroke and tumor, LC: aneurysm/trauma) I T A M I: migraine (transient homonymous hemianopsia) N: optic tract or lateral geniculate body lesion

Question 72

Vitreous opacities

Answer 72

V: VH I: inflammatory cells from vitritis/posterior uveiits, snowball opacities of pars planitis or sarcoidosis T: FB A M: rarely - amyloidosis or Whipple dz I: asteroid hyalosis, synchysis scintillans, normal vistreous strands from age-related vitreous degeneration, hyaloid remnants N: tumor cells