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
- 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
- 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.
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
- 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).
of visual loss
Red eye" - vision
- acute angle-closure
glaucoma (headache; mid-dilated pupil, shallow anterior chamber,
normal or swollen optic nerve)
- herpetic eye disease
(foreign body sensation; dendritic lesion of cornea with fluorescein
staining represent herpes simplex; pustular rash represents herpes
- corneal ulcer (pain
and photophobia; white spot in cornea) iritis (photophobia; circumcorneal
- scleritis (ocular tenderness;
localized or diffuse scleral redness)
- orbital cellulitis (eyelids
tensely swollen; reduced ocular movement; swollen optic nerve
in advanced cases)
Sudden, painless visual
- diabetic eye disease
(absent red reflex from vitreous hemorrhage or cataract; blood
or exudate in maculopathy)
- retinal detachment (unremitting
visual field defect, like a shadow or curtain," possible
reduced red reflex; usually difficult to see detachment with
- ischemic optic neuropathy
(visual field defect; afferent pupil defect, pale optic nerve
swelling with splinter hemorrhages on disc surface)
- retinal artery or vein
occlusion (may see embolus and sludging of blood in venules with
artery occlusion; large, may see tortuous veins and retinal hemorrhages
in vein occlusion)
- macular degeneration
(hemorrhage or scarring in fovea)
painless visual loss
- cataract (reduced red
- macular degeneration
(drusen or scarring in fovea)
- diabetic retinopathy
(cataract or retinal hemorrhages and exudates)
- glaucoma (enlarged central
cup "cupping" of optic nerve head)
- compressive optic neuropathy
(pale optic nerve)
- eyelid problems (droopy
eyelid from excess eyelid skin or from weak eyelid muscle)
Management or referral
- Conditions requiring
- 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
- 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.