Hello, and welcome to DigiSNEC. This is an e-learning platform where we have uploaded lectures for the benefit of residents in SNEC and beyond. In this lecture, we’re going to take you through an approach to common ocular complaints. They aren’t all that many ocular complaints that you’ll hear in our clinics, which is a good thing. And we’re going to try to keep it as simple as possible for you to be able to dichotomize the various approaches that we have, to make it easier as you go through the clinics. The content of these lectures– of this particular lecture is going to include these approaches, which is number one, blurring or loss of vision, red eye, diplopia or double vision, floaters, and finally Leucocoria, or white pupillary reflex. I’m not going to go through the details of each diagnosis that may come under the headings. That’s for you to go back and read on. However, this will help you organize your thoughts when you come across patients complaining of these symptoms and maybe a combination of these symptoms or there may be just the one main symptom that they’re complaining of. So let’s– to get started we’ll talk about blurring of vision. Blurring Of Vision, or BOV, may be transient, or it may be persistent. When I say transient, I mean it resolves within, typically within, 24 hours, but usually it’s much faster than that. Persistent blurring of vision may painless or painful. If it’s painless, it may be an acute onset or chronic onset. So that’s how you can think it through. In regards to transient vision loss, if it lasts a few seconds on and off, typically it could suggest a papilledema, or disc swelling, bilateral disc swelling. Bilateral disc swelling due to raised intracranial pressure is what we call papilledema, by the strict sense of the definition. And these patients, they tend to be sick, they may have a space occupying lesion intracranially leading to increased intracranial pressure, or a bleed in the brain, intracranial hemorrhage that results in this. Sometimes for example, patients with idiopathic intracranial hypertension may also present with transient visual obscuration. And you might, on examination, find them to have papilledema or disc swelling. Sometimes bilateral disc swelling may be a result of malignant hypertension, which needs to be ruled out immediately because this is a life threatening condition. The patient, of course, may have other symptoms as well. Sometimes acute changes in blood pressure may also lead to transient visual obscuration. For transient vision loss that last a few minutes, you have to think of more of an ischemic or embolic phenomenon. For example, Amaurosis fugax, which may be defined as a TIA, or Transient Ischemic Attack involving the visual system. Typically these patients complain of a curtain that slowly covers their vision, and this curtain gets lifted with time, typically within one hour. So these patients must be worked up for further ischemic risk factors subsequently, because they may be predisposed to getting stroke subsequently. Sometimes also these may also be symptomatic of patients who are about to develop central retinal artery occlusion, due to an embolic phenomenon. So these patients need to have a full ocular assessment to rule all that out, and subsequently need to be referred on for workup of ischemic risk factors. Vertebrobasilar insufficiency may also result in transient vision loss. And migraines may also result in transient vision loss that may last a few minutes, 20 to 30 minutes, and may be followed on by a headache. Sometimes patients with these kind of vision loss may also have vision loss that respects the vertical midline, vertical meridian, such that– or patients with seizures, for example, may also have such symptoms, wherein they lose vision in half their visual field, either right or left. These are rarer. Moving on to blurring of vision that is persistent and painless. If it’s an acute, painless vision loss, it may be due to a central retinal vascular event, like a CRAO, Central Retinal Artery Occlusion, which can result in significant vision loss. Central Retinal Vein Occlusion may also lead to vision loss, and typically it’s not as devastating as the CRAO, unless the CRVO is ischemic in nature. Ischemic optic neuropathy may also result in vision loss. It may be posterior ischemic optic neuropathy, or anterior ischemic optic neuropathy. And anterior may be further classified into arteritic and non-arteritic. Vitreous hemorrhage can occur in patients, for example, commonly the patients who have proliferative diabetic retinopathy. Sometimes patients with a breakthrough bleed from macular lesions, like a PCV or exudative AMD can also have vitreous hemorrhage, causing sudden loss of vision in one eye. Macular lesions, like as I mentioned exudative AMD, can result in this vision loss. Macular hole is also– can cause devastating vision loss especially– there are four stages, I’d like you to read that up– of macular hole, clinically speaking. And there are various causes for macular hole, which you should read up on. Central serous retinopathy is another cause of blurring of vision that is unilateral, typically unilateral, and acute and painless. But these patients may not have significant vision loss. What they may complain more of is micropsia, bit of metamorphopsia, bit of hyperopic shift. Of course, an acute intracranial event, like a stroke or hemorrhagic infarct or, for example, occipital lobe infarct can result in a painless loss of vision. For gradual, painless loss of vision, it may be due to common causes like refractive error, cataract– patients may only be noticing once they perhaps get a posterior subcapsular cataract, or with time they find their vision getting dimmer, less contrast. That’s a very common cause of gradual onset vision loss. Dry AMD, dry ARMD may also result in gradual onset vision loss and diabetic maculopathy. Less common causes but– what you can rule out with an examination– include chronic corneal conditions, like corneal dystrophies, for example, Fuchs’, endothelial corneal dystrophy, or keratoconus can result in this, even some rare optic neuropathies, like metabolic optic neuropathy. Here’s some examples that you can have a look at. For example in here, you can have a look at retinal detachment. Here it’s more inferior. Of course, you need to see better. There’s a bit of macular involvement that will be better seen on a 3D microscope, by microscopy. This patient here– this is showing a right eye with a blood and thunder appearance, depicting central retinal vein occlusion. This very classical picture of a cherry red spot, characteristic of central retinal artery occlusion of the left eye. This patient has a wet ARMD, exudative age-related macular degeneration with sub-retinal hemorrhage, resulting in vision loss in the left eye. And this patient here has a bit of pre-retinal and vitreous hemorrhage, resulting in vision loss of the right eye. Here you can see this patient has a cataract. And this patient has a dry ARMD with some bruising on the left posterior pole. This patient has diabetic retinopathy, and there are some– there’s some macular edema with hard exudates, some macroaneurysms, and [INAUDIBLE] hemorrhages. So this, the maculopathy is what causes a bit of blurred vision. And this is a classic picture of a keratoconus, a very thin cone, as you can see, para-centrally. [INAUDIBLE] persistent and painful vision loss. If you have a typical case, it would be a patient, and slightly middle aged to elderly Chinese lady coming in, holding her hand to the eye, complaining of nausea, vomiting, one sided headache, bit of halos, a lot of blurred vision in that eye. That is classic picture of acute angle closure glaucoma, an attack of angle closure glaucoma. Lens-induced glaucoma can also result in sudden loss of vision associated with pain. Uveitis can also result in a dull, achy sort of pain, resulting in some blurring of vision. Optic neuritis typically they will have pain on movement of the eye. Corneal conditions, of course, can result in quite significant pain and some vision loss, depending on where the lesion is. Here are some examples. This is not a great picture, but it shows the eye in a mid-dilated state. If you cast a slit, you’ll notice that the angle is very shallow. This patient has acute angle closure glaucoma. This patient here has a bit of uveitis, with a hypopyon. So you need to be careful, you need to rule infective causes in this particular case, of course. The patient has optic neuritis. And this patient here has a corneal ulcer with a hypopyon. This patient has an epethelial corneal abrasion resulting in pain and blurring of vision. Let’s move on to red eye. When managing red eye, you need to know whether is it common cause of red eye, like sore eyes in a conjunctivitis– like viral conjunctivitis– or are there more dangerous reasons why the patient might be having a red eye. If it’s unilateral especially, you need to be concerned. So when you look at red eye you need to know a few things. There’s a few ways to look at it, bilateral, unilateral. Other factors to consider are whether the patient has discharge along with the red eye. How is the patient’s VA, or Visual Acuity? Any pain? How’s the pupil like? Any change in intraocular pressure? OK, let’s talk about red eye with minimal discharge. Patients with minimal ocular discharge, minimal pain, could be conditions like a simple, spontaneous subconjuctival hemorrhage. The patient might have just woken up and may have noticed the eyes are red, and there’s a patch of red, very well defined red patch over the eye, the white of the eye. And that could just be a simple, spontaneous subconjuctival hemorrhage, which typically has no other serious sequelae. It could be allergic conjunctivitis, which has– may have, sometimes, minimal mucoid discharge. Depending on severity the allergic conjunctivitis, it could just be a pterygium. Sometimes it may– pterygium may have some associated inflammation, or it may be just that the patient happened to notice a growth on his conjunctiva, which he brought to the attention of his GP and they’re referring on to you. Or could just be simple blepharoconjunctivitis, wherein they have lid disease resulting in some redness of the eye, some pain, and at least a bit of dryness, and a bit of discomfort. Mild to moderate pain. Once again, dry eye syndrome, just like blepharoconjunctivitis can lead to that. Episcleritis is a bit more, slightly more sinister. It’s inflammation of the episclera layer of the eye. They typically may have either generalized or sectoral redness that is usually unilateral. Corneal disorders, just a lot of epithelial defects in the cornea, due to dry eyes, for example. Or anterior uvetitis, which is basically inflammation of the anterior uvea, can result in also red eye with a bit of pain. Typically also these tend to be unilateral. Pain, with severe pain like I mentioned earlier, acute angle closure glaucoma can present with severe pain, redness, and blurring of vision. Corneal disorders like an abrasion, an erosion, corneal ulcer, corneal foreign body, all these can result in severe pain and blurring of vision and red eye. Scleritis has bit more deep seated, significant pain that would typically wakes the patient up from sleep. It has a very– it may be sectoral, it may be generalized redness. Usually it’s unilateral as well. Of course, a bit rarer but more dangerous causes is endophthalmitis, which is basically sight threatening with infection of the whole eye. Here are some examples. This basically just shows chemosis in a patient some allergic conjunctivitis. This is a typical case of a subconjuctival hemorrhage, which is spontaneous, well defined borders. This is a pterygium. This shows the inflammation of the episcleral layer, so it’s episcleritis. This is a patient with a bit of uveitis and hypopyon. So once again, when there’s hypopyon and uveitis, you need to exclude infective causes or it could just be purely inflammatory. This patient has a corneal ulcer with a bit of hypopyon. This patient has significant hypopyon injected eye, and of course, you do need to rule out dangerous conditions, like endophthalmitis when you see this. And here you can see a bit of violaceous hue, very deep seated redness suggestive of scleritis, anterior scleritis. Commonly patients with bilateral red eye and discharge, and they have a typical history of having a bit of a viral prodrome, have a bit of a fever, have a bit of a flu prior to getting this, or they may have a bit of a contact history. The commonest cause is, of course, viral conjunctivitis, sometimes bacterial conjunctivitis. Other causes include blepharitis– which can present with mild pain sometimes, or a bit of discharge sometimes– and allergic conjunctivitis. Less common causes which are dangerous include, once again, infective conjunctivitis. But, for example, the hyperacute type, like gonococcal conjunctivitis, sometimes chlamydia related conjunctivitis. These happen sometimes in neonates, within one week of birth. So you need to be very careful, because this can be potentially sight threatening. Dacryocele, or dacryocystitis, can result in a bit of a red eye with some discharge. Canaliculitis, basically involving the tear drainage system, or corneal ulcer, or even endophthalmitis can result in red eye with discharge. Here are some examples. This patient has conjunctivitis, bilateral red eyes, quite puffy, sometimes can be even hemorrhagic, and have a lot of discharge. Otherwise, usually, typically their vision is not so affected. This patient here has a dacryocystitis, dacryocele here. Probably chronic, but now it looks slightly inflamed and injected, so you do need to treat this patient. This patient– just looking at the lids, showing a bit of meibomian gland disease. Moving on now to diplopia, or double vision. This may occur sometimes– you’ll see patients, especially in our setting in Singapore, complaining of double vision or blurred vision. But when you ask them, they say it’s transient and associated with a bit of blurred vision, and it resolves when they use eye drops or when they blink the eyes a few times. So this is quite common. It could just be due to dry eyes, so in which case you don’t need to really be too concerned. When they are quite certain that they do have double vision, you need to first ascertain whether it’s binocular or monocular. And a simple way to do that is to ask if the diplopia persists on occlusion of one eye. If there’s still double vision when they occlude one eye, then it’s a monocular diplopia. Diplopia is only there when they’re opening both eyes, it’s binocular. So here’s a table for you to look through and read up on, when it’s binocular or monocular diplopia. Monocular typically tends to be ocular pathologies, like refractive error, pathology of the ocular media, like keratoconus, resulting in a bit of significant astigmatism. Large iris defects sometimes can lead to it, for example, patients who might have undergone laser peripheral iridotomy, for example, primary angle closure suspect or angle closure disease. Lens dislocation can result in that, and then sometimes macular conditions, like CSR, can result in this perception of monocular diplopia. Binocular diplopia, we’re a bit more concerned. It could be due to neuropathy, for example, nerve palsy, like third nerve palsy, fourth cranial nerve palsy, or sixth cranial nerve palsy, or even a combination of these can result in binocular diplopia, in which case you need to ascertain whether it’s vertical, horizontal, or torsional. If it’s intermittent and you were able to find out on exam that there’s not full ocular motility, could it be due to myasthenia gravis? Is it associated fatigability? Sometimes other conditions, like internuclear ophthalmoplegia can also result in diplopia on certain gaze. Orbital disease, like thyroid eye disease, can also result in double vision, binocular double vision. Any orbital collision, for example, that causes the ocular position to move, or causes a restriction of the ocular motility, like in a tumor or fracture, for example, with muscle entrapment can result in binocular diplopia, and needs to be addressed. Strabismus sometimes can also result in double vision. This picture here shows a patient with the right sixth nerve palsy. She’s unable to abduct her right eye. That’s why she has a double vision, more on right gaze, for example. This patient has a right orbital floor fracture with inferior rectus entrapment, resulting in double vision on up gaze. This patient has left third nerve palsy. As you can see, this is the patient in central position. There’s the patient in right gaze. We can see the patient’s left eye is in down and out position, unable to really go up, unable to really go down, unable to even adduct. So this patient has a left third nerve palsy. Of course, a third nerve palsy is an entire new approach. You need to know whether it’s pupil involving, surgical third or the medical third. I would like you to read up on that as well. Let’s move on to floaters. Floaters are basically mobile opacities in the vitreous, which cast shadows on the retina. So patients will typically notice floaters, or they’ll say a spider web moving or circles moving in the eye, especially in bright light settings. It may be associated flashes of light, or photopsia, which you can even physiologically get– induce by massaging your eyeball. Causes of photopsia basically could be migraine, like a zigzag pattern, or sometime this last, like an aura, preceding a migrainous attack. Those are more colorful usually, a scintillating photopsia. Or rapid eye moment in the dark can also give you possession of photopsia. Or sometimes when it’s associated with floaters, it may be due to retinal tear or retinal detachment, so you need to be a bit more careful. Floaters, the commonest cause could just be vitreous degeneration. It’s common in myopes [INAUDIBLE] because they have a long eyeball, and vitreous is liquefied and the vitreous particles are floating, which they perceive as floaters. A retinal tear may also result in a sudden acute increase in floaters and photopsia. When a patient complains of a sudden increase in the number of floaters with a lot of photopsia that doesn’t resolve, you need to rule out retinal tear, or in a worst case scenario, retinal detachment. Uveitis can sometimes result, especially intermediate uveitis, can sometimes result in a perception of floaters. And vitreous hemorrhage may also result in a perception of floaters, which they can sometimes describe as red or black. Here you can see a typical [INAUDIBLE] string. This is posterior vitreous detachment, amongst the commonest causes of floaters, especially chronic floaters. This is the attachment of a vitreous around the papillary region that is now detached, and the patient can see a circle sometimes floating in front of his eye. A retinal tear, quite significant retinal tear here, resulting in perception of floaters and blurred vision. And that you can see here, an inferior retinal detachment. And this, once again, is depicting vitreous hemorrhage. Lastly we are talking about leucocoria, or white pupil reflex, which occurs when you shine light onto the pupil and you observe a white, rather than a typical red, pupil reflex. There are many causes for this, but the most dangerous cause, because it’s life threatening and sight threatening, is retinoblastoma in a child. Other causes include congenital cataract, retinal conditions, like retinopathy of prematurity, retinal detachment, Coats disease, persistent fetal vasculture, and other infections, like toxocasiasis and toxoplasmosis. So I hope that this has given you all an overall summary of the common ocular complains that we get to see as eye doctors in our center. And a brief dichotomized approach as to how you could think through patients, these complaints when they come to you, how you can organize your thoughts. And this will probably help you as you go further down the path of training in ophthalmology. Thank you.