The student should have basic knowledge of the anatomy and physiology of the eye and adnexae. Skills in interviewing a patient will also be helpful.
INTENDED USERS
Although this material was developed to provide the medical students with knowledge on ocular symptomatology, this should be supplemented by small group learning directed to developing their skills in taking ocular history.
CONTENT
Ocular symptoms can be classified into three general types:
1. abnormalities of vision
2. abnormalities of ocular appearance
3. abnormalities of ocular sensation – pain and discomfort These symptoms should always be described according to
1. onset – gradual, rapid or asymptomatic
Example of asymptomatic onset is that the blurring of vision was discovered only when patient inadvertently covered one eye.
2. duration – brief, chronic
3. frequency – continuous, intermittent 4. degree – mild, moderate or severe
5. location – focal or diffuse, unilateral or bilateral
Determine if forms of treatment have already been initiated/tried. If so, to what extent have they helped to relieve the symptoms? Are there circumstances that provoke or worsen the condition? Is this the first time these symptoms are experienced? No associated other signs/symptoms?
1. ABNORMALITIES OF VISION A. Visual Loss
Patients can describe visual loss as “nanlalabo”, “maulap ang panningin”, “nawawala ang paningin” or “nabulag”
When a patient reports impairment of vision, the examiner should determine when it occurred, whether onset was sudden or gradual, whether one or both eyes were affected.
If both eyes are involved, which is worse, which failed first and how much time has elapsed between the two.
Actual onset of visual impairment may not coincide with the time given by the patient.
Vision in one eye may have been deteriorating over the years, becoming noticeable when the patient accidentally covered one eye.
One should distinguish between decreased central acuity and peripheral vision.
Disturbances in peripheral vision may be focal such as scotoma, or may involve a bigger area as in hemianopsia. A scotoma is a blind or partially blind area in the visual field while hemianopsia is blindness in one-half of the visual field. Abnormalities in the central nervous visual pathway disturb the visual field more than the central visual acuity.
Is the visual loss transient or permanent? Transient loss of vision may be to vascular disorders anywhere from the retina to the occipital cortex.
Is the patient’s vision worse or better in some circumstances ? Patients with error of refraction may have better vision when they squint their eyes. Patients with presbyopia will read better if they position their reading material further away from their eyes.
Patients with central focal cataracts may have worse vision in bright sunlight.
Decline in visual acuity may be due to abnormalities anywhere along the optical and neurologic pathway. Consider the following as possible causes:
1. refractive error 2. ptosis
3. ocular media disturbance (corneal edema, hyphema, cataract, vitreous hemorrhage)
4. retinal abnormalities 5. optic nerve diseases
6. intracranial visual pathway abnormalities
B. Visual Aberrations
1. GLARE, PHOTOPHOBIA
Patients may describe this as “silaw” or “nasisilaw”
Irritative disease of the conjunctiva or cornea specially foreign bodies of the cornea may induce photophobia. Acute inflammation of the iris may likewise make the eye sensitive to ordinary light.
Glare may also result from uncorrected EOR, scratches on spectacle lenses, excessive pupillary dilatation, hazy ocular media
2. VISUAL DISTORTION
Manifests as irregular patterns of dimness, wavy or jagged lines, image magnification/
minification. May be caused by migraine, optical distortion from strong corrective lenses, lesions involving the macula and optic nerve.
3.FLASHING/FLICKERING LIGHTS
Patients may describe this as “may parang kidlat”, “biglang may maliwanag”
May indicate retinal traction, or migrainous scintillations.
4.FLOATING SPOTS
“May lumulutang sa harap ng mata”
May represent normal vitreous strands due to “normal” vitreous changes.Or may be secondary to pathologic presence of pigments, blood, or inflammatory cells.
5.OSCILLOPSIA
“Gumagalaw o lumilikot and paningin”
Shaking field of vision may be due to harmless lid twitching (myokymia), or to certain forms of nystagmus
6. DOUBLE VISION
“Nagdadalawa ang paningin” “doble ang paningin”, naduduling”
Monocular diplopia manifests as a split shadow or ghost image. Causes include uncorrected error of refraction, media abnormalities such as cataract, corneal irregularities
Binocular diplopia disappears when one eye is covered may be vertical, horizontal, diagonal or torsional. The diplopia may be more severe ( 2 images more widely separated) in certain gazes or head position.
2 ABNORMALITIES OF APPEARANCE A. Red Eye
Must differentiate between redness of the lids and periocular area (ocular adnexa) from that of the globe.
Preseptal cellutitis VS Conjunctivitis “namumula ang mata”, “sore eyes”
Orbital cellulits Subconjunctival hemorrhage “dumugo ang mata”
“Namamaga ang mata” Scleritis Iritis
Acute glaucoma Pterygium etc Color abnormalities other than redness
1. jaundice
2. hyperpigmented spots (on the iris/ocular surface) – examples are Nevus of Ota , subepithelial melanosis
B. Ptosis – drooping of the eyelids, “Napipikit”, “kirat ang mata”
C. Focal growths – in the eyelids or eye surface , “bukol”, “maga”
D. Exopthalmos – protrusion of the eyeball, “lumuluwa ang mata”
E. Ocular deviation or misalignlent – “duling”, “banlag” ; esodeviation (inward turning of the eye), exodeviation (outward turning of the eye), hypertropia (upward turning of the eye) or hypotropia (downward turning of the eye)
3. ABNORMALITIES OF OCULAR SENSATION A. Eye Pain
“Masakit”, “makirot”, “mahapdi”
Must be characterized in terms of location:
1. periocular (may be tenderness of the lid, tear sac, sinuses or temporal artery) 2. retrobulbar (due to orbital inflammation, orbital myositis, optic neuritis)
3. ocular (may be due to corneal abrasion, corneal foreign body, glaucoma, endophthalmitis) 4. non-specific (fatigue from ocular accommodation, binocular fusion, or referred discomfort from
non-ocular tension or fatigue)
Deep seated aching, boring or throbbing pain may be may be due to inflammation of the iris and ciliary body.
Orbital infection can give rise to severe pain. Herpez zoster may give pain in the eye before any visible involvement of the eye and may persist after the disease has resolved.
Tenderness, soreness or pain on pressure may be due to inflammation of the lids, corneal foreign body or any anterior segment inflammation.
B. Eye Irritation
Superficial discomfort is usually caused by ocular surface abnormalities
2. Dryness – Burning, gritty, mild foreign body sensation. Can occur with dry eyes or other types of mild corneal irritation, “may buhangin”, “maaligasgas”
3. Tearing – may be due to irritation of the ocular surface; or may be a sign of abnormal lacrimal drainage , “nagluluha”
4. Ocular Secretions – “nagmumuta”, Characretize discharge as to color, consistency, amount a Mucoid discharge – allergic
b Mucopurulent – bacterial/viral conjunctivitis c Dried matter/crusts on lashes – Blepharitis C. Headache
Uncorrected errors of refraction and presbyopia frequently cause headache referred to the eyes or brow and comes with reading and computer work. Migraine headaches and sinusitis are frequent causes of headache.
Headaches may not come from the eye. High and low blood pressure may also give rise to headaches around the eyes. Headache from rise in intracranial pressure is usually severe and associated with nausea and vomiting.
SUMMARY
Ocular symptoms consist of abnormalities in vision, appearance and sensation. The student should ask clarifying questions in order to get sufficient detail to pinpoint the etiology of the ocular disorder.
REFERENCE
1. Riordan-Eva, Whitcher, John. Vaughn and Ashbury’s General Ophthalmology , 16th Edition, New York:
Lange Medical Books/ McGraw Hill, 2004
2. Scheie, Harold, Albert, Daniel. Textbook of Ophthalmology. Philadelpia : W.B Saunders