Lisa F. Rosenberg, M.D.


The most common symptoms elicited from ocular diseases are few in number and nonspecific in nature: blurred vision, pain, and redness. The most common ocular abnormalities can often be differentiated by a simple history and basic eye exam in your office.

Cataracts, macular degeneration, and glaucoma occur most frequently in older people and have significant impact onan individual's quality of life. There are effective therapies and visual aids for these potential vision-limiting conditions. Visual symptoms caused by cataracts may be improved initially by glasses, and later by surgical lens extraction and lens implantation. Cataract surgery is an elective procedure, to be considered when the patient has sufficient difficulty in carrying out his or her daily visual needs (i.e., driving, reading, sewing, hobbies). Some forms of macular degeneration are amenable to laser treatment, which slows the sometimes relentless progression of the disease. It is critical that patients with macular degeneration are reassured that although they may lose the ability for fine central vision (i.e., reading vision, driving vision), they will never go totally blind; they will be able to carry out their lives independently. On the other hand, patients with glaucoma are at great risk for going completely blind. The incidence of glaucoma in the elderly population varies between 10% and 30%. It is essential that patients over 65 be examined every one to two years to discover this "sneak thief" of sight. Many kinds visual aids, such as spectacles, magnifying lenses, lamps, and devices, are available to assist and improve low vision in patients.


Visual loss
Sudden or gradual?
Sudden visual loss implies a vascular occlusion (retinal artery or vein), retinal or vitreous hemorrhage, or retinal detachment. Gradual visual loss may be due to cataract, macular degeneration, or glaucoma.
Painful or painless?
Painful visual loss may be due to an inflammatory condition or acute angle-closure glaucoma.
Central or peripheral?
Central vision loss (reading vision) implies an abnormality in the macula or optic nerve. Peripheral vision loss suggests a retinal abnormality, advanced optic nerve damage from glaucoma, or a compressive CNS lesion.
Transient or prolonged?
A transient visual loss suggests a vascular abnormality in the retina (embolus) or brain (posterior circulatory or carotid insufficiency).
Monocular or binocular?
Vision loss in one eye suggests an optic nerve lesion or intrinsic eye disease or carotid artery branch disease. Bilateral vision loss may be due to cataracts, glaucoma, or macular degeneration.

Physical exam

The most important components of an office eye examination which will distinguish the presence of serious causes of visual disturbances are visual acuity, red reflex, and fundoscopy.

Visual acuity
With patient's glasses on, perform with near card held at any distance that achieves best acuity. Test one eye at a time. Unless the patient has an eye condition that has been confirmed stable, all patients in whom reduced ( < 20/20) visual acuity has been found should be referred to an ophthalmologist.
Red reflex
In a dimly lit room, observe pupil through the ophthalmoscope held about 1 foot from the patient. An absent or reduced red reflex indicates an opacity of the cornea (infection or scar), lens (cataract), or vitreous hemorrhage.
Fundus exam
Visualization of the optic nerve for pallor (compressive lesion), enlarged optic cup or asymmetric optic nerve appearance between the two eyes (glaucoma), swelling with blurred disc margins (ischemic optic neuropathy if unilateral; hypertensive optic neuropathy or increased intracranial pressure if bilateral). Observation of the macula for blood (diabetic retinopathy or macular degeneration), scarring (macular degeneration), or yellow dots (exudates from diabetic retinopathy or drusen from macular degeneration).

Differential diagnosis of visual loss

Sudden, painful visual loss

Red eye" - vision threatening disorders

Sudden, painless visual loss

Gradually progressive, painless visual loss

Management or referral

Conditions requiring urgent referral
include those causing a painful eye, often red, with reduced vision (acute glaucoma, corneal ulcer, traumatized eye, intraocular infection after eye surgery) and conditions causing sudden and profound visual loss with or without pain (retinal artery occlusion, retinal detachment)
Conditions which may be managed without referral
include nonvision-threatening ocular conditions - "red eye" with normal vision
Subconjunctival hemorrhage
localized or diffuse; no treatment unless recurrent or due to significant trauma. Occurs commonly with ASA use and coughing.
tearing; watery discharge; sometimes mucopurulent discharge. Usually self-limited and does not require antibiotics.
itching, burning, foreign-body sensation; erythematous lid margins; crusting of lid margins. Treatment with warm compresses BID and baby shampoo eyelid scrubs with warm washcloth.
tender local swelling or eyelid (becomes nontender with chronicity). Treat with warm compresses QID
Dry eyes
foreign body sensation, blurred vision worse at end of day; vision improves with blinking. Treat with lubrication: artificial tears QID to hourly; tears ointment QHS. Refer in refractory cases for tear duct occlusion.

**Topical corticosteroids risk causing elevated eye pressure, cataracts, and potentiating eye infections, particularly herpes and ulcers. It is recommended that they be used only while under the supervision of an ophthalmologist.

**Remember that antiglaucoma medications are often overlooked as sources of systemic side effects including congestive heart failure, dysrhythmias, exacerbation of asthma, depression, impotence, and electrolyte imbalance.