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the left, the left eye fails to cross the midline. Diplopia occurred as a result of a left abducens palsy secondary to carcinomatous meningitis.

Head tilt may be a sign of an extraocular muscle weakness. A weakness of the superior oblique muscle, often resulting from birth trauma, may not be recognized until much later in life. Diplopia may develop associated with a characteristic head tilt. The head is habitually held in such a position as to avoid horizontal, vertical, or torsional diplopia. Figure 10-146 illustrates the classic head tilts associated with paralysis of the oblique muscles. With a superior oblique palsy (see Fig. 10-146A and B), the face is turned and the head is tilted to the uninvolved side;the chin is depressed. With an inferior oblique palsy (see Fig. 10-146C and D), the face is turned to the uninvolved side, the head is tilted to the involved side, and the chin is elevated. Head tilt also may be seen in paralysis of the vertical rectus muscles.

The retinal findings of common diseases are summarized in Table 10-11. Many common diseases display their disorders at the macula of the retina. Table 10-12 provides a differentiation of some of these lesions.

Figure 10-146 Classic head-tilt positions in patients with palsies of the oblique muscles. A, Right superior oblique. B, Left superior oblique. C, Right inferior oblique. D, Left inferior oblique.

Table 10-11

Retinal Characteristics of Common Diseases

Condition

Primary Findings

Distribution

Secondary Findings

Posterior pole

Diabetes (see Figs. 10-89 to 10-101)

Hypertension (see Figs. 10-80, 10-83, and 10-102 to 10-106)

Papilledema (see Figs. 10-107 to 10-109)

Retinal vein occlusion (see Figs. 10-117 and 10-118)

Retinal arterial occlusion

Microaneurysms Neovascularization Retinitis proliferans*

Arteriolar narrowing ''Copper wiring'' Flame hemorrhages Arteriovenous nicking

Hyperemia of the disc Venous enlargement Retinal hemorrhages Disc elevation

Loss of spontaneous venous pulsations Cotton-wool spots

Hemorrhages Neovascularization

Pallor of retina Decreased width of artery Embolus possibly visible

Posterior pole

Posterior pole

On or near disc

Confined to area drained by affected vein

Hard exudates{ Deep hemorrhages Retinal venous occlusions Vitreous hemorrhages

Hard exudates Deep hemorrhages Retinal venous occlusions Vitreous hemorrhages

Hard exudates Optic atrophy, late

Exudates

Confined to area supplied Optic atrophy, late

Table 10-12 Differentiation of Common Macular Lesions

Feature Macular Degeneration*

Macular Star{

Circinate Retinopathy*

Appearance Pigmentary mottling, often with hemorrhage

Whitish exudate that radiates around macula

Broken ring-shaped whitish exudate around macula

Papilledema

Papillitis

Central retinal vein occlusion

Diabetes

Central retinal vein occlusion

•Often bilateral in elderly patients. See Figures 10-121 and 10-123. {See Figure 10-105. {See Figure 10-92.

Useful Vocabulary

Listed here are the specific roots that nology related to diseases of the eye.

are important for understanding the termi-

Root

Pertaining to

Example

Definition

blepharo-

eyelid

blepharoplasty

Surgical repair of eyelid

choroi-

choroid

choroiditis

Inflammation of the choroid

-cor- (or -kor-)

pupil

anisocoria

Unequal pupils

cyclo-

ciliary body

cycloplegia

Paralysis of accommodation

dacryo-

tear

dacryocystitis

Inflammation of the lacrimal sac

-duction

to lead

abduction

Turning outward

Continued

Table 10-11 Retinal Characteristics of Common Diseases—cont'd

Condition

Primary Findings

Distribution

Secondary Findings

Arteriolar sclerosis

Widening of light reflex ''Copper wiring'' Arteriovenous nicking

Throughout retina

Decrease in retinal pigment

Blood dyscrasias (see Fig. 10-110)

Diffuse hemorrhages Venous dilation, common Roth's spots (hemorrhagic lesions with white centers)

Sickle cell disease

Sharp cutoff of arterioles Arteriovenous anastomoses Neovascularization in ''sea fan'' formations (resembling the marine organism with a similar pattern)

Peripheral retina

Vitreous hemorrhages Retinal detachments

*A growth of a light-colored sheet of opaque connective tissue over the inner surface of the retina. Neovascularization of the tissue with tortuous vessels is seen. These vessels bleed easily.

{Exudate is the term used for small intraretinal lesions caused by retinal disturbances in a variety of disorders.

Useful Vocabulary—cont'd

Root

Pertaining to

Example

Definition

irid-

iris

iridectomy

Surgical excision of part of the iris

kerato-

cornea

keratopathy

Disease of the cornea

lacri-

tears

lacrimal

Pertaining to the tears

nyct-

night

nyctalopia

Night blindness

-ocul-

eye

intraocular

Within the eye

ophthalm-

eye

ophthalmoscope

Instrument for visualizing the retina

-opsia

vision

hemianopsia

Blindness in half of the visual field

-phak(os)-

lens

aphakia

Without a lens

photo-

light

photosensitive

Sensitive to light

presby-

old

presbyopia

Impairment of vision as a result of increasing age

tars-

eyelid structure

tarsorrhaphy

Surgical suturing of the lid

-trop-

turn

esotropia

Eye turning inward

Writing Up the Physical Examination

Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the eye.

Visual acuity is OD 20/20 and OS 20/30 according to the standard Snellen chart. The visual fields by confrontation field testing are normal. Examination of the external structures of the eyes is normal. The pupils are equal, round, and reactive to light and to accommodation.* The extraocular movements' are normal. On ophthalmoscopic examination, the disc margins are sharp. A normal cup-disc ratio is present. The vasculature is normal.

• Visual acuity is OD 20/60 and OS 20/20 according to the pocket visual acuity card. Examination of the eyes reveals marked conjunctival injection on the right with a dilated pupil on the same side. The pupils are round and are reactive to light. The visual fields by confrontation field testing are normal. The optic disc margins are sharp, and the vascularity of both retinas appears normal.

• The patient is able to read the newspaper without corrective lenses. The extra-ocular movements are normal. The left pupil is miotic and is 2 mm smaller than the right pupil. A mild ptosis of the left upper lid is present. Both pupils react to light directly and consensually. Confrontation fields are within normal limits. Funduscopic examination is within normal limits.

• The visual acuity with corrected lenses appears normal. There is a paralysis of abduction of the left eye, accompanied by diplopia on attempted left lateral gaze. The pupils are equal, round, and reactive to light. The optic disc margins are sharp. The vasculature is normal.

• There is decreased visual acuity in both eyes. The patient has difficulty reading 4-inch [6.35-mm] print in the newspaper at about 6 inches [15 cm] with his right eye. There is OS NLP. The examination of the external eye is normal. The extraocular movements are intact. The left optic disc margin is slightly blurred on its nasal aspect. The cup-disc ratio is normal. There are multiple, soft, cotton-wool exudates seen bilaterally. A large, flame-shaped hemorrhage is seen in the right eye at the 2 o'clock position. Arteriovenous nicking is present bilaterally.

• The visual acuity is OD 20/40 and OS 20/100 according to the pocket visual acuity card. A bitemporal hemianopsia is present by confrontation field testing. EOMs are normal. Ophthalmoscopic examination reveals blurring of both optic discs with loss of spontaneous venous pulsations. A flame-shaped hemorrhage is present in the right eye one disc diameter at the 10 o'clock position.

*Often abbreviated as PERRLA, although accommodation cannot really be tested.

{Often abbreviated as EOMs.

Bibliography

Albert DM, Jakobiec FA: Atlas of Clinical Ophthalmology. Philadelphia, WB Saunders, 1996.

Ambati J, Ambati BK, Yoo SH, et al: Age-related macular degeneration: Etiology, pathogenesis, and therapeutic strategies. Surv Ophthalmol 48:257, 2003.

Batterbury M, Bowling B: Ophthalmology: An Illustrated Colour Text. Edinburgh, Churchill Livingstone, 1999.

Cassirer R: The Philosophy of Symbolic Forms. London, Oxford University Press, 1955.

Herbella FA, Mudo M, Delmonti C, et al: ''Raccoon eyes'' (periorbital haematoma) as a sign of skull base fracture. Injury 32:745, 2001.

Kanski JJ, Nischal KK: Ophthalmology: Clinical Signs and Differential Diagnosis. London, Harcourt, 2000.

Leibowitz HM: The red eye. N Engl J Med 343:345, 2005.

Michelson JB, Friedlaender MH: Color Atlas of the Eye in Clinical Medicine, Mosby-Wolfe, London, 1996.

Rowe S, MacLean CH, Shekelle PG: Preventing visual loss from chronic eye disease in primary care: Scientific review. JAMA 291:1487, 2004.

Spaide RF: Diseases of the Retina and Vitreous. Philadelphia, WB Saunders, 1999.

Steinmann WC, Millstein ME, Sinclair SH: Pupillary dilation with tropicamide 1% for funduscopic screening: A study of duration of action. Ann Intern Med 107:181, 1987.

Vafadis G: When is red eye not just conjunctivitis? Practitioner 246:469, 2002.

Witmer AN, Vrensen GFJM, Van Noorden CJF, et al: Vascular endothelial growth factors and angiogenesis in eye disease. Prog Retin Eye Res 22:1, 2003.

Zadnik K: The Ocular Examination: Measurements and Findings. Philadelphia, WB Saunders, 1997.

Zarbin MA: Current concepts in the pathogenesis of age-related macular degeneration. Arch Ophthalmol 122:598, 2004.

CHAPTER 11

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