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Manual for Eye Examination and Diagnosis, Ninth edition. Mark Leitman.

© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.

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Chapter 1

Medical history

The history includes the patient’s chief com-plaints, medical illnesses, current medications,allergies to medications, and family history ofeye disease.

Common chief complaints Causes

Persistent loss of vision 1 Focusing problems are the most common complaints.Everyone eventually needs glasses to attain perfect vision, and fi tting lenses occupies half the eye care professional’s day.

2 Cataracts are cloudy lenses that occur in everyone in later life. Unoperated cataracts are the leading cause ofblindness worldwide. In the USA, over 3.3 million cataractextractions are performed each year.

3 Thirteen percent of American adults are treated for diabetes. Another 40% are pre-diabetic. It is the leading cause of blindness in the USA in those under 65 years of age.

4 Age-related macular degeneration (AMD) causes lossof central vision and is the leading cause of blindness inpeople over age 65. Signs are present in 25% of people overage 75, increasing to almost 100% by age 100.

5 Glaucoma is a disease of the optic nerve that is usuallydue to elevated eye pressure. It mostly occurs after age 35and affects 2 million Americans, with black persons affectedfi ve times as often as white persons. Peripheral vision is lost fi rst, with no symptoms until it is far advanced. This is whyroutine eye exams are recommended.

Transient loss of vision lasting less than ½ hour, with or without fl ashing lights

In younger patients, think of migrainous spasm of cerebralarteries. With aging, consider emboli from arterioscleroticplaques.

Floaters Almost everyone will at some time see shifting spots dueto suspended particles in the normally clear vitreous. Theyare usually physiologic, but may result from hemorrhage,retinal detachments, or other serious conditions.

Flashes of light (photopsia) The retina accounts for 84% of complaints, which areusually unilateral. Simple sparks are most often due tovitreous traction on the retina (Fig. 523). Insults to the visualcenter in the brain (16%) are most often migrainous, butministrokes, especially in the elderly, must be considered.Cerebral causes are often bilateral, with more formedimages, such as zigzag lines (Fig. 133).

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Common chief complaints Causes

Night blindness(nyctalopia)

Nyctalopia usually indicates a need for spectacle change,but also commonly occurs with aging and cataracts.Rarer causes include retinitis pigmentosa and vitamin Adefi ciency.

Double vision (diplopia) Strabismus, which affects 4% of the population, is thecondition where the eyes do not look in the same direction.This binocular diplopia disappears when one eye is covered.In straight-eyed persons, diplopia is often confused withblurry vision or caused by hysteria or a beam-splittingopacity in one eye that does not disappear by covering theother eye.

Light sensitivity(photophobia)

Usually, a normal condition treated with tinted lenses, butcould result from infl ammation of the eye or brain; internal refl ection of light in lightly pigmented or albinotic eyes; or dispersion of light by mucous, lens, and corneal opacities, orretinal degeneration.

Itching Most often due to allergy and dry eye.

Headache Headache patients present daily to rule out eye causes andto seek direction.

1 Headache due to blurred vision or eye-muscle imbalanceworsens with the use of eyes.

2 Tension causes 80–90% of headaches. They typicallyworsen with anxiety and are often associated with bilateraltemple and neck pain.

3 Migraine occurs in 18% of women and 6% of men. Thisrecurrent pounding headache, often lasting for hours,but less than a day, is sometimes accompanied by nausea,bilateral blurred vision, and fl ashing, zigzag lights. It is relieved by sleep and may be aggravated by bright lightand certain foods.

4 Sinusitis causes a dull ache about the eyes and occasionaltenderness over a sinus (Fig. 207). There may be anassociated nasal stuffi ness and a history of allergy.

5 Menstrual headaches are cyclical.

6 Sharp ocular pains lasting for seconds are often referredfrom nerve irritations in the neck, nasal mucosa, orintracranial dura, which, like the eye, are also innervated bythe trigeminal nerve.

7 Headaches that awaken the patient and are prolongedor associated with focal neurologic symptoms should bereferred for neurologic study.

Visual hallucinations These most often occur in the elderly, especially in thosewith dementia, psychosis, or reduced sensory stimulation,as in blindness and deafness. Many medications, includingcephalosporins, sulfa drugs, dopamines used to treatParkinson’s disease, vasoconstrictors, or vasodilators shouldbe considered.

Increased tearing(epiphora)

Consider increased production due to emotion and eyeirritation or decreased ability of a normally generated tearto drain into the nose.

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Fig.  1 Thyroid exophthalmos with exposed sclera at superior limbus.

Medical illnesses

Record all systemic diseases. Diabetes and thy-roid disease are two that are most commonlyassociated with eye disease.

Diabetes mellitus

1 Diabetes (see Front cover image) may be fi rst diagnosed when there are large changes in spectacle correction causing blurriness. It is due to the effect of blood sugar changes onthe lens of the eye.2 Diabetes is one of the common causes of III, IV, and VI cranial nerve paralysis. It is due to closure of brainstem vessels. The resultingdiplopia may be the fi rst symptom of diabetesand often resolves by 10 weeks.3 Retinopathy due to microvascular disease may result in macular edema. It is the primaryreason for blindness before age 65. Patientswith diabetes should have annual eye exams,because early treatment is critical. As retinop-athy is rare in children, most Type 1 diabeticscreenings may be delayed until a child is 15,or 5 years after diagnosis.

Autoimmune (Graves’) thyroid disease

This is a condition in which an orbitopathy may be present with hyper- but also hypo- or euthyroid disease.

1 It is the most common cause of bulging eyes, referred to as exophthalmos (proptosis). This is due to fi broblast proliferation and mucopol-ysaccharide infi ltration of the orbit. A small white area of sclera appearing between the lid and upper cornea is diagnostic of thyroid dis-ease 90% of the time (Figs 1 and 2 ). This exposed sclera may be a result of exophthalmos or thy-roid lid retraction due to stimulation of Müller’s muscle that elevates the lid. Severe orbitopa-thy may be treated with steroids, radiation, or surgical decompression of the orbit (Fig. 3 ). 2 Infi ltration of eye muscles may cause diplopia, which is confi rmed by a computedtomography (CT) scan (Figs 2 and 3 ).

Fig.  2 CT scan of thyroid orbitopathyshowing fi ltration of medial rectusmuscle (M) and normal lateral rectusmuscle (L). Compression of left optic nerve could cause optic neuropathy.This is called crowded apex syndrome.Courtesy of Jack Rootman.

Fig.  3 Orbital CT scan of Graves’orbitopathy before surgical decompression (above) and afterright orbital fl oor osteotomy (below).Often three, but rarely all four, bonywalls may be opened. Note thickened extraocular muscles. Courtesy of LelioBaldeschi, MD, and Ophthalmology, yyJuly 2007, Vol. 114, pp. 1395–1402.

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3 Exophthalmos may cause excessive expo-sure of the eye in the day and an inability toclose the lids at night (lagophthalmos), result-ing in corneal dessication. 4 Optic nerve compression is the worst com-plication and occurs in 4% of patients withthyroid disease. It could cause permanent lossof vision (Fig. 2 ) and immediate intravenous steroids should be considered when vision is threatened.

Medications (ocular side effects)

Record patient medications. Those taking the following commonly prescribed drugs are often referred to an eye doctor to monitorocular side effects.

Hydroxychloroquine (Plaquenil), initially used to treat malaria, is now a cornerstone medication used to treat autoimmune dis-eases, such as rheumatoid arthritis, lupus erythematosus, and Sjögren’s syndrome. It may cause “bull’s eye” maculopathy (Fig. 4 ) and corneal deposits. Patients should get a baseline eye exam before starting medica-tion. It includes visual acuity, Amsler grid, color vision, and examination of the retina to rule out pre-exisiting maculopathy. The patient should follow-up every 6 months. Depending on the dosage and the chronic-ity of use, the eye doctor will determine if additional tests are necessary. Risk increases if dosage exceeds 6.5 mg/kg, especially when taken for more than 5 years and if there is pre-existing macular degeneration. These high-dose patients may also have routine monitoring of their peripheral visual fi elds and optical coherence tomography (OCT) testing for parafoveal retinal pigment epi-thelial cell damage.

The retina is also adversely affected by phe-nothiazine tranquilizers (Fig. 5 ); niacin, a lipid-lowering agent; tamoxifen, used for breast cancer (Figs 6–8 ); and interferon used to treat multiple sclerosis and hepatitis C.

Ethambutol, rifampin, isoniazid, streptomy-cin – taken mainly for tuberculosis – may all cause optic neuropathy. The antidepressants

Fig.  4 Bull’s eye maculopathy dueto hydroxychloroquine in a patientwith systemic lupus. The vasculitisand white cotton-wool spots aredue to the lupus. Courtesy of RusselRand, MD, and Arch. Ophthalmol. , Apr. 2000, Vol. 118, pp. 588–589.Copyright 2000, American MedicalAssociation. All rights reserved.

Fig.  5 Phenothiazine maculopathywith pigment mottling of the macula.

Fig.  7 Tamoxifen causes cataracts.

Fig.  6 Tamoxifen maculopathy with crystalline depositis (A); and (B)OCT showing crystals in the fovea.Courtesy of Joao Liporaci, MD.

(A) (B)

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Paxil, Prozac, and Zoloft may also cause optic neuropathy. Corticosteroids may cause posterior subcapsular cataracts (Fig. 400), glaucoma, and a reduction in immunity that may increase the incidence of herpes keratitis.

Flomax (tamsulosin), the most common treatment for an enlarged prostate gland,increases the complications in cataract sur-gery by decreasing the ability to dilate thepupil, a condition referred to as intraoper-ative fl oppy iris syndrome (IFIS). Pupillary expansion devices (Fig. 9 ) and additional pupillary dilating medications usually preventcomplications.

Stevens–Johnson syndrome (Fig. 10 ) is an immunologic reaction to a foreign sub-stance, usually drugs, and most commonly sulfonamides, barbiturates, and penicillin. Some 100 other medications have also been implicated. It often affects the skin and mucous membranes. It could be fatal in 35% of cases.

Prostaglandin analogues are the most com-monly prescribed glaucoma medications.They may irreversibly darken the iris (Fig. 11 ) with reversible lengthening and darkening ofthe eyelashes and skin of the lids (Fig. 13 ). Theside effect of longer, darker lashes has gener-

Fig.  8 Besides causing maculopathy and cataracts, tamoxifen also causescrystal deposition in the cornea(keratopathy). Courtesy of OlgaZinchuk, MD, and Arch. Ophthalmol. ,July 2006, Vol. 124, p. 1046.Copyright 2006, American MedicalAssociation. All rights reserved.

Fig.  9 Iris retractors are one methodused to open poorly dilated pupilsduring cataract surgery. Note edge oflens implant (↑) behind iris. Courtesyof Bonnie Henderson, MD, HarvardMedical School.

Fig.  10 Stevens–Johnson syndrome with infl ammation and adhesions of lidand bulbar conjunctiva. Reprinted withpermission from Am. J. Ophthalmol. , Aug. 2008, Vol. 1146, p. 271. Surgicalstrategies for fornix reconstruction. Based on Symblepharon Severity, yyAhmad Kheirhah, Gabriella Blanco,Victoria Casas, Yasutaka Hayashida, Vadrecu K. Radu, Scheffer C.G. Tseng.Copyright 2008, Elsevier.

Fig.  11 Irreversible darkening of ablue iris after 3 months of latanoprost(Xalatan) therapy. This is the mostcommon drug for treating glaucoma.Courtesy of N. Pfeiffer, MD, P.Appleton, MD, and Arch. Ophthalmol. , Feb 2011, Vol. 119, p. 191. Copyright2001, American Medical Association.All rights reserved.

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ated a drug: Latisse. It is applied once a day to the upper eyelid lashes for cosmetic reasons.This group of drugs may also reduce orbitalfat, causing a sunken upper lid sulcus (Fig. 12 ).

Amiodarone (Cordarone, Pacerone), one of the most potent anti-arrhythmia drugs, andsildenafi l (Viagra), tadalafi l (Cialis), and var-denafi l (Levitra), used to treat erectile dys-function, have all been suspected of causingnonarteritic anterior ischemic optic neuropa-thy. Amiodarone almost always causes depos-its in the cornea that rarely reduce vision, butmay cause glare (Fig. 14 ).

Allergies to medications

Inquire about drug allergies before eye drops are placed or medications prescribed. Neomy-cin, a popular antibiotic eye drop, may cause conjunctivitis and reddened skin (Fig. 15 ).

Fig.  13 After long-term use of prostaglandin analogue in the left eye, the patient developedhyperpigmentation of periorbital skin, darkening and lengthening of lashes, and loss of orbital fat, causing a deepening of the upper eyelid sulcus.

Fig.  14 Epithelial deposits radiatingfrom a central point in the inferiorcornea. They occur in almost allpatients with Fabry’s disease, whichis an X-linked systemic accumulationof a glycosphingolipid. Easily seen on a slit lamp exam, it can be the fi rstclue in recognizing the presence ofthis disease, which is amenable to therapy. Indistinguishable deposits eventually appear in almost all patients using amiodarone and withhydroxychloroquine. Courtesy of NealA. Sher, MD, and Arch. Ophthalmol. , Aug. 1979, Vol. 97, pp. 671–676.Copyright 1979. American Medical Association. All rights reserved.

(A)

Fig.  12 (A) Prostaglandin-analogue-induced fat atrophy of the leftorbit with sunken superior sulcus after 1 year (↑) and darkened skin (∧). Courtesy of University of Iowa, Eyerounds.org. (B) After discontinuing eye drops that had been used in the left eye for 1 year, orbital fat atrophy,darkened and lengthened lashes,and improved skin pigmentation areseen. Courtesy of N. Pfeiffer, MD, P.Appleton, MD, and Arch. Ophthalmol. , Feb 2011, Vol. 119, p. 191. Copyright2001, American Medical Association.All rights reserved.

(B)

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A special question should be directedto the smoking of cigarettes since it doubles the rate of cataracts, maculardegeneration, and all types of uveitis.It also worsens exophthalmos in thy-roid disease. Cigarette smoking andsmokeless tobacco use among Amer-ican adults is about 20%. At age 70,80% of Americans have high bloodpressure. Over 50% of adults are dia-betics or pre-diabetic. It is predictedthat 1 in 3 children born after the year 2000 will develop Type 2 diabetes. Onethird of Americans are obese and onethird are overweight. Remind patientsthat a major change in lifestyle is needed to stem the pandemic of thesechronic diseases. Patients should be reminded about minimizing consump-tion of red and preserved meats, salt,sugar, and saturated fats. Recommend instead a diet rich in fruits, vegetables, beans, nuts, fi sh, and whole-grain cere-als. Staying thin, stress reduction, and aroutine daily exercise program shouldalso be advocated.

Family history of eye disease

Cataracts, refractive errors, retinal degenera-tion, and strabismus – to name a few – may all be inherited. In glaucoma, family membershave a 10% chance of acquiring the disease. Eighty percent of people with migraine have an immediate relative with the disease.

Fig.  15 Neomycin allergy occurs in 5–10% of the population.