Wills DDx of ocular Sx

Question 1

Burning More common

Answer 1

Blepharitis
meibomitis
dry eye syndrome
conjunctivitis (infectious, allergic, mechanical, chemical)

Question 2

Burning Less common

Answer 2

Cornea problem 
inflammed pterygium/pinguecula
episcleritis
superior limbic keratoconjunctivitis
ocular toxicity (medication, CL solution, makeup)

Question 3

Decreased Vision - transient visual loss

+More common

Answer 3

*transient visual loss (VA returns to normal w/in 24 hrs usually w/in 1 hour)

Few seconds (usually bilateral): papilledema
Few min: amaurosis fugax (TIA u/L), vetebrobasilar artery insufficiency (bilateral)
10-60 min: migraine (w/or w/o subsequent headache)

Question 4

Decreased Vision - transient visual loss

+Less common

Answer 4

*transient visual loss (VA returns to normal w/in 24 hrs usually w/in 1 hour)
impending CRVO
ischemic optic neuropathy
ocular ischemic syndrome (carotid occlusive dz)
glaucoma
sudden change in BP
CNS lesion
ON drusen
GCA

Question 5

Decreased Vision > 24 hrs-sudden, painless (MC)

Answer 5

Retina artery or vein occlusion
ischemic optic neuropathy
VH
RD
optic neuritis (usually pain with eye movements)
sudden discovery of pre-existing u/L visual loss

Question 6

Decreased Vision > 24 hrs-sudden, painless (LC)

Answer 6

other retina or CNS dz (e.g. stroke)

methanol poisoning

Question 7

Decreased vision - gradual, painless loss (over weeks, months, years) = MC

Answer 7

Cataract
Refractive error
POAG
chronic retina dz (ARMD)
Diabetic retinopathy

Question 8

Decreased vision - gradual, painless loss (over weeks, months, years) = LC

Answer 8

chronic cornea disease (e.g. cornea dystrophy)

optic neuropathy/atrophy (e.g. CNS tumor)

Question 9

Decreased VA (painful loss)

Answer 9

acute angle closure glaucoma
optic neuritis (pain with eye movement)
uveitis
endophthalmitis
cornea hydrops (keratoconus)

Question 10

Decreased VA (post-traumatic visual loss)

Answer 10

eyelid swelling
cornea irregularity
hyphema
ruptured globe
traumatic cataract
lens dislocation
commotio retinae
RD
retina/vitreous hemorrhage
traumatic optic neuropathy
CNS injury

Question 11

Always remember in VA loss

Answer 11

nonphysiologic visual loss

Question 12

Distortion of vision (MC)

Answer 12

• Refractive error: including presbyopia, acquired myopia (from cataract, DM, ciliary spasm, medications, RD surgery)
• Acquired astigmatism (e.g. from anterior segment surgery, chalazion, orbital fracture, & edema)
• macular disease [e.g. CSR, macular edema, ARMD, CNVM)
• cornea irregularity
• intoxication (EtOh, methanol)
• pharmacologic (scopolamine patch)

Question 13

Distortion of vision (LC)

Answer 13

Keratoconus
topical eye drops (miotics, cycloplegics)
RD
migraine (transient)
hypotony
CNS abnormality (including papilledema)
nonphysiologic

Question 14

Monocular Diplopia (MC)

Answer 14

refractive error
incorrect spectacle alignment
corneal opacity or irregularity (including corneal or refractive surgery)
cataract
iris defects (e.g. iridectomy)

Question 15

Monocular Diplopia (LC)

Answer 15

Dislocated natural lens or lens implant
macular disease
RD
CNS causes (rare)
nonphysiologic

Question 16

Binocular diplopia (typically intermittent)

Answer 16

myasthenia gravis

intermittent decompensation of existing phoria

Question 17

Binocular diplopia (constant)

Answer 17

isolated CN3/4/6 palsy
orbital disease (e.g. TED, orbital pseudotumor, tumor)
cavernous sinus/superior orbital fissure syndrome
status-post ocular surgery (e.g. residual anesthesia, displaced muscle, undercorrection or overcorrection after muscle surgery, restriction from scleral buckle, severe aniseikonia s/p refractive surgery)
s/p trauma (e.g. orbital wall fracture with extraocular muscle entrapment, orbital edema)
INO
vertebrobasilar artery insufficiency
Other CNS lesion
spectacle problem

Question 18

Eyelash loss

Answer 18

trauma
burn
thyroid disease
VKH
eyelid infection or inflammation
radiation
chronic skin disease 
cutaneous neoplasm
trichotillomania

Question 19

Eyelid crusting MC

Answer 19

blepharitis, meibomitis, conjunctivitis

Question 20

Eyelid crusting LC

Answer 20

canaliculitis, nasolacrimal duct obstruction, dacryocystitis

Question 21

Eyelid swelling associated with inflammation (MC)

Answer 21

hordeolum
blepharitis
conjunctivitis
preseptal/orbital cellulitis
trauma
contact dermatitis
HSV/zoster dermatitis

Question 22

Eyelid swelling associated with inflammation (LC)

Answer 22

ectropion
cornea abnormalitiy
urticaria/angioedema
blepharochalasis
insect bite
dacyroadenitit
erysipelas
eyelid/lacrimal gland mass
autoimmunities (discoid lupus, dermatomyositis)

Question 23

Eyelid swelling noninflammatory

Answer 23

chalazion
dermatochalasis
prolapse of orbital fat (retropulsion of the globe increases the prolapse)
laxity of the eyelid skin
cardiac
renal
thyroid eye disease
superior venal cava syndrome
eyelid/lacrimal gland mass
foreign body

Question 24

Eyelid twitch

Answer 24

orbicularis myokymia (related to fatigue, excess caffeine, medication or stress)
cornea/conjunctival irritation (especially from an eyelash, cyst, or conjunctival foreign body)
dry eye
blepharospasm (bilateral)
hemifacial spasm
albinism (photosensitivity)
serum electrolyte abnormality
tourettes
tic douloureux
anemia (rare)

Question 25

Eyelids unable to close (lagophthalmos)

Answer 25

``` severe proptosis severe chemosis eyelid scarring eyelid retractor muscle scarring CN7 palsy s/p facial cosmetic/reconstructive surgery ```

Question 26

eyes "jumping" (oscillopsia)

Answer 26

``` acquired nystagmus INO myasthenia gravis vestibular function loss opsoclonus/ocular flutter SO myokymia various CNS disorders ```

Question 27

Flashing lights (more common)

Answer 27

``` retinal break/detachment PVD migraine rapid eye movements (particular in darkness) oculodigital stimulation ```

Question 28

Flashing lights (less common)

Answer 28

``` CNS (particularly occipital lobe disorders) vestibulobasilar artery insufficiency optic neuropathies retinitis entoptic phenomena hallucinations ```

Question 29

FB sensation

Answer 29

``` dry eye blephriatis conjunctivitis trichiasis K abnormalitiy (Abrasion/FB) recurrent erosion SPK contact lens related problem episcleritis pterygium pinguecula ```

Question 30

Glare

Answer 30

``` cataract pseudophakia posterior capsular opacity corneal irregularity or opacity altered pupillary structure or response status-post refractive surgery posterior vitreous detachment pharmacologic (e.g. atropine) ```

Question 31

Hallucinations (formed images)

Answer 31

``` PVD (white lightning streaks of Moore) RD optic neuropathies blind eyes bilateral eye patching Charles Bonnet syndrome psychosis parietotemporal area lesions other CNS causes medications ```

Question 32

Halos around lights

Answer 32

``` cataract pseudophakia posterior capsular opacity acute angle-closure glaucoma or cornea edema from another cause (e.g. aphakic/pbk, CL overwear) cornea dystrophies s/p refractive surgery corneal haziness discharge pigment dispersion syndrome vitreous opacities drugs (e.g. digitalis, chloroquine) ```

Question 33

Itchy Eyes

Answer 33

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

Question 34

photophobia with abnormal eye exam (MC)

Answer 34

``` cornea abnormality (e.g. abrasion or edema) anterior uveitis ```

Question 35

photophobia with abnormal eye exam (LC)

Answer 35

``` conjunctivitis (mild photophobia) posterior uveitis scleritis albinism total color blindness aniridia mydriasis of any etiology (pharmacologic, traumatic) congenital glaucoma ```

Question 36

photophobia with normal eye exam

Answer 36

``` migraine meningitis retrobublar optic neuritis subarachnoid hemorrhage trigeminal neuralgia lightly pigmented eye ```

Question 37

Night blindness (MC)

Answer 37

refractive error (esp undercorrected myopia) advanced glaucoma or optic atrophy small pupil (esp from miotic gtts) retinitis pigmentosa CSNB s/p PRP drugs (phenothiazines, chloroquine, quinine)

Question 38

Night blindness (LC)

Answer 38

vitamin A deficiency, gyrate atrophy, choroideremia

Question 39

Ocular pain (typically mild to moderate)

Answer 39

``` dry eye blepharitis infectious conjunctivitis episcleritis inflammed pinguecula or pterygium FB (cornea or conjunctival) corneal disorder (SPK) superior limbic keratoconjunctivitis ocular medication toxicity CL-related problems post-operative ocular ischemic syndrome eye strain from uncorrected refractive error ```

Question 40

Typically moderate to severe ocular pain

Answer 40

``` corneal disorder (e.g. abrasion, erosion, infiltrate/ulcer/keratitis, chemical injury, UV burn) trauma anterior uveitis, scleritis endophthalmitis acute angle-closure glaucoma ```

Question 41

Periorbital pain

Answer 41

``` trauma hordeolum preseptal cellulitis dacyrocystitis dermatitis (e.g. contact, chemical, varicella zoster, or herpes simplex) referred pain (e.g. dental, sinus) tic douloureaux ```

Question 42

Orbital

Answer 42

``` sinusitis trauma orbital cellulitis idiopathic orbital inflammatory syndrome orbital tumor or mass optic neuritis acute dacryoadenitis migraine or cluster headache diabetic cranial nerve palsy ```

Question 43

asthenopia (nonspecific symptoms such as fatigue, pain in or around the eyes, blurred vision, headache and occasional double vision)

Answer 43

``` uncorrected refractive error phoria or tropia convergence insufficiency accommodative spasm pharmacologic (miotic) ```

Question 44

red eye: adnexal causes

Answer 44

``` trichiasis distichiasis floppy eyelid syndrome entropion/ectropion lagophthalmos blepharitis meibomitis acne rosacea dacyocystitis canaliculitis ```

Question 45

red eye: conjunctival causes

Answer 45

``` ophthalmia neonatorum in infants conjunctivitis (bacterial, viral, chemical, allergic, atopic, vernal, medication toxicity) subconjunctival hemorrhage inflamed pingeucula superior limbal keratoconjunctivitis giant papillary conjunctivitis conjunctival foreign body symblepharon and associated etiologies (e.g. OCP, S-J syndrome, toxic epidermal necrolysis) conjunctival neoplasia ```

Question 46

red eye: cornea causes

Answer 46

``` infections/inflammatory keratitis CL related problems cornea foreign body recurrent corneal erosion pterygium neurotrophic keratopathy medicamentosa UV or chemical burn ```

Question 47

red eye: other

Answer 47

``` trauma post-operative dry eye syndrome endophthalmitis anterior uveitis episcleritis scleritis pharmacologic (e.g. prostaglandin analogs) angle-closure glaucoma carotid-cavernous fistula cork-screw conjunctival vessels cluster headache. ```

Question 48

spots in vision (MC)

Answer 48

PVD intermediate/posterior uveitis VH vitreous condensations/debris

Question 49

spots in vision (LC)

Answer 49

microhyphema/hyphema RD or retinal break cornea opacity or FB Note: some pts are referring to a blind spot in their visual field 2/2 retinal, ON, CNS disorder

Question 50

Tearing: Adults (pain present)

Answer 50

``` K abnormality (e.g. abrasion, FB, rust ring, recurrent erosion, edema), anterior uveitis eyelash or eyelid disorder (trichiasis, entropion) conjunctival foreign body dacryocystitis dacryoadenitis canaliculitis trauma ```

Question 51

Tearing: minimal/no pain

Answer 51

``` dry eye syndrome blepharitis nasolacrimal duct obstruction punctal occlusion lacrimal sac mass ectropion conjunctivitis (especially allergic and toxic) emotional states crocodile tears (congenital or CN7 palsy) ```

Question 52

children

Answer 52

nasolacrimal duct obstruction congenital glaucoma cornea or conjunctival foreign body or other irritative disorder