Referral to an ophthalmologist is usually the first step in a good workup. If one is not available, a careful eye examination including slit lamp examination, visual acuity evaluation, tonometry, and visual field studies should be done. If these are unrevealing, a referral to an ophthalmologist or neurologist should be made without further delay. Additional studies would include a CT scan or MRI of the brain and orbits, carotid scans, spinal tap, VEP studies, and four-vessel cerebral angiography. An EEG would be useful in diagnosing hysterical blindness and malingering.
History
–Be aware that patients often have vision reduction over time (e.g., from cataracts) and only perceive the loss as sudden
–Onset, duration, trauma; transience vs permanence of visual loss or change
–Associated signs and symptoms of demyelinizing disease, toxoplasmosis, bartonellosis, Lyme disease
–PMH including migraines, hypertension, diabetes, thyroid disease, rheumatic disease, vascular disease, atrial fibrillation, lipid status
- Physical exam
–Obtain visual acuity and confrontation visual fields in
both eyes
–Redness, pain, photophobia
–Pupillary evaluation: look for Marcus Gunn pupil,
which usually differentiates optic nerve from other
causes
–Extraocular muscle evaluation
–Perform a dilated fundus evaluation
–Evaluate for proptosis
-
Radiology
–CT or MRI of orbits and brain is indicated for
associated neurologic signs, history of trauma
-
Evaluation for stroke if right- or left-sided
-
Ophthalmology consultation for dilated retinal exam, evaluation, and management
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
BLURRED VISION, BLINDNESS, AND SCOTOMATA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful eye examination with magnification and fluorescence to rule out a foreign body and ulcers is essential in the acute case of blurred vision. Ophthalmoscopic examination may reveal optic neuritis or a retinal vein thrombosis. Visual field examination by confrontation may reveal a field defect. If these test results are negative, ocular tension should be checked to rule out glaucoma. A history of migraine, the use of birth control, and alcohol intake must be investigated. If there is headache on the side of the lesion, a sedimentation rate is done, steroids should probably be started immediately, and referral to a neurologist made promptly in case temporal arteritis is possible, especially in the aged. Otherwise, referral to an ophthalmologist is necessary. The ophthalmologist will perform visual field examinations with perimetry, a slit lamp examination, and look for refractive errors. If other neurologic findings are present, a CT scan, skull x-ray film, and spinal tap may be indicated. A neurologic consultant can determine this.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Vision loss:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss.) Don’t touch the eye if the patient has perforating or penetrating ocular trauma.
If the patient’s vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the visual loss occur abruptly, or did it develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask him about the location, intensity, and duration of any eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing the eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 630.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 521.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 206.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vision loss:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Sudden vision loss can signal an ocular emergency. Don’t touch the eye if the patient has a perforating or penetrating ocular trauma. (See Managing sudden vision loss, page 802.)
If the patient’s vision loss occurred gradually, ask him if it affects one eye or both and all or only part of the visual field. Is the vision loss transient or persistent? Did it occur abruptly or develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask about the location, intensity, and duration of any eye pain. Also, obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing the eye examination is to assess visual acuity with the best available correction in each eye. (See Testing visual acuity, page 803.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (see “Pupils, nonreactive,” page 654) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 246.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Night blindness [Nyctalopia]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of difficulty seeing at night, ask when he first noticed the problem. Is it intermittent or steadily worsening? Is it worse at certain times or in certain conditions? Also, ask about other ocular symptoms, such as eye pain, blurred or halo vision, floaters or spots, and photophobia.
Explore any history of glaucoma, cataracts, and familial degeneration of vision. If no ocular problems are apparent, briefly evaluate the patient’s nutritional status for vitamin A deficiency.
Examine the eyes for ptosis, abnormal tearing, discharge, and conjunctival injection. Test visual acuity and visual fields in both eyes and, if trained and equipped, measure intraocular pressure. Check pupillary response, and evaluate extraocular muscle function by testing the six cardinal fields of gaze.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vision loss:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Sudden vision loss can signal an ocular emergency. Don’t touch the eye if the patient has perforating or penetrating ocular trauma.
If the patient’s vision loss occurred gradually, ask him if it developed over hours, days, or weeks. Does it affect one eye or both? Does it affect all or part of the visual field? Is the vision loss transient or persistent? What’s the patient’s age? Ask whether he has experienced photosensitivity, and ask him about the location, intensity, and duration of eye pain. Obtain an ocular history, including history of eye problems or systemic diseases that may lead to eye problems, such as infections, cancer, hypertension, diabetes mellitus, and thyroid, rheumatic, or vascular disease.
Physical examination
Assess visual acuity and determine the best available vision correction in each eye. (See Testing visual acuity.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 306.) Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex and the effect of accommodation. (See Vision loss: Causes and associated findings, pages 308 and 309.)
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Vision loss:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss, page 690.)
If the patient’s vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the visual loss occur abruptly, or did it develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask him about the location, intensity, and duration of any eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Night blindness:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient complains of difficulty seeing at night, ask when he first noticed the problem. Is it intermittent or steadily worsening? Is it worse at certain times or in certain conditions? Also, ask about other ocular symptoms, such as eye pain, blurred or halo vision, floaters or spots, and photophobia.
Explore any history of glaucoma, cataracts, and familial degeneration of vision. If no ocular problems are apparent, briefly evaluate the patient’s nutritional status for vitamin A deficiency.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vision loss:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss, page 628.) Don't touch the eye if the patient has perforating or penetrating ocular trauma.
If the patient's vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the vision loss occur abruptly or did it develop over hours, days, or weeks? What's the patient's age? Ask the patient if he has experienced photosensitivity and ask him about the location, intensity, and duration of eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing an eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 629.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 515.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 197.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Blurred Vision, Blindness, and Scotomata:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful eye examination with magnification and fluorescence to rule
out a foreign body and ulcers is essential in the acute case of blurred
vision. Ophthalmoscopic examination may reveal optic neuritis or a retinal
vein thrombosis. Visual field examination by confrontation may reveal a
field defect. If these test results are negative, ocular tension should be
checked to rule out glaucoma. A history of migraine, the use of birth
control pills, and alcohol
intake must be investigated. If there is headache on the side of the lesion,
a sedimentation rate is done, steroids
should probably be started immediately, and referral to a neurologist made
promptly in case temporal arteritis is possible, especially in an aged
individual. Otherwise, referral to an ophthalmologist is necessary. The
ophthalmologist will perform visual field examinations with perimetry and a
slit lamp examination, and will look for refractive errors. If other neurologic findings are present,
a CT scan, skull x-ray film, and spinal tap may be indicated. A neurologic
consultant can determine this.
-1.5pt
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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