1

Differential diagnosis

Common DD questions

Dry eye syndrome Pigmented conjunctival lesions Resistant corneal ulcer Interstitial keratitis Peripheral corneal thinning Corneal edema Management of chronic non-infectious uveitis Investigate a case of posterior uveitis Phakomatosis Iris nodules Leucocoria Subretinal neovascular membranes Cherry red spot Bulls eye maculopathy Macular edema Night blindness Pigmented fundus lesion Ocular manifestations of blunt trauma Ocular manifestations of blood diseases Ocular manifestations of renal diseases Anisocoria Optic cupping Optic disc swelling Diplopia Compressive neuropathy Restrictive myopathy Unilateral proptosis in children

Differential diagnosis

Oculoplasty Causes of madarosis

I. Local 1. Ch ant lid margin disease 2. Infiltrating tumours 3. Burns 4. Radiotherapy or cryotherapy of lid tumours II. Skin disorders 1. Generalized alopecia 2. Psoriasisi III. Systemic disorders 1. Myxoedema 2. SLE 3. Syphilis 4. Leprosy IV. Following removal 1. Iatrogenic trichiasis 2. Trichotillomania

Causes of lid retraction

I. Thyroid eye disease II. Neurogenic 1. Contolat unilat ptosis 2. Facial palsy..(unopposed LPS action) 3. CN3 misdirection 4. Marcus Gunn jaw winking 5. Collier sign of midbrain (Parinaud synd.) 6. Hydrocephalus 7. Sympathomimetic drops III. Mechanical 1. Surgical overcorrection of ptosis 2. Scarring of UL skin IV. Congenital 1. Isolated 2. Duane retraction synd 3. Down synd 4. Transient eye popping

Causes of excessive watering of the eye

I. Lacrimation Corneal & conj lesions irritation of V CN reflex ++ tear production II. Lacrimal pump failure LL laxity & weak OO (facial palsy,)

Differential diagnosis

III.

Obstructive epiphora 1. Punctual stenosis a. Primary 1. Idiopathic 2. Trachoma 3. HSV 4. Cicatrizing conjuctivitis 5. Irradiation b. Secondary 1. Punctual eversion (ectropion,) 2. Canalicular obstruction a. Idiopathic b. HSV c. Systemic 5-FU d. Chronic dacryocystitis e. Cicatrizing conjuctivitis 3. NLD-obstruction a. Congenital b. Acquired 1. Idiopathic 2. Trauma 3. Irradiation 4. Wegner granulomatosis 5. Nasopharyngeal tumors

Causes of Unilateral proptosis

1. 2. 3. 4. 5. 6. Graves disease Orbital cellulites Orbital varix A-V fistula Orbital tumors Hemorrhage, aneurism

Causes of Bilateral proptosis

1. 2. 3. 4. 5. 6. 7. 8. Graves disease C.S thrombosis (late) Empyema of paranasal sinuses Lymphoma, leukemia Tumors extending from nose, pharynx Metastasis Vasculitis Oxycephaly

Differential diagnosis

Causes of Axial proptosis

1. 2. 3. 4. 5. 6. Graves disease Op N meningioma Op N glioma Cavernous hemangioma Metastasis A-V malformation

DD of mass in Superotemporal orbit (lacrimal region)

1. 2. 3. 4. 5. Dermoids Prolapsed lacrimal gland Lacrimal gland tumor; pleomorphic adenoma, carcinoma Lymphoma IOID

DD of mass in Superonasal orbit

1. 2. 3. 4. 5. 6. Mucocoele, mucopyocoele Encephalocoele Neurofibroma Dermoids Osteoma lymphoma

Orbital tumours
I. Vascular 1. Capillary haemangioma 2. Cavernous haemangioma 3. Lymphangioma II. Lacrimal gland 1. Pleomorphic adenoma 2. Carcinoma III. Neural 1. Op n glioma 2. Op n sheath meningioma 3. Neurofibroma IV. Miscellaneous 1. Lymphoma 2. Rhabdomyosarcoma V. Metastatic 1. Tumour invasion from adjacent sinuses

Differential diagnosis

Pediatric: proptosis
1. 2. 3. 4. 5. 6. 7. 8. 9. Rhabdomysarcoma Orbital cellulitis Inflammatory pseudotumour Optic nerve glioma Retrobulbar hge Thyroid ophthalmopathy Chloroma Neuroblastoma histocytosis

DD of rapidly expanding orbital lesion in infancy

1. 2. 3. 4. 5. Capillary haemangioma Rhabdomyosarcoma Lymphangioma chloroma Neuroblastoma 6. Cellulitis

Metastatic orbital tumours in children

1. 2. 3. 4. Neuroblastoma Ewing sarcoma Chloroma Langerhans-cell Histocytosis a. Eosinophilic granuloma b. Hand-Schuller-Christian disease c. Letterer-Sewe disease

Differential diagnosis

Conjunctiva Conjunctival discharge

I. Watery 1. Acute viral 2. Acute allergic II. Mucoid 1. Vernal 2. KC sicca III. Purulent 1. Severe acute bacterial IV. Mucopurulent 1. Mild bacterial 2. chlamydial

Subconjunctival hge
I. Microvascular diseases II. Increased CVP III. Trauma IV. infection 1. Viral a. Entero virus 70 b. Coxsackie virus A24 c. Adenovirus d. A hgic conjitis 2. Bacterial a. Strept. pneumoniae b. H. aegyptius V. Amyloidosis

Causes of conj membranes

I. True membranes 1. Diphtheria 2. B-haemolytic streptococci II. Pseudomembranes 1. Severe adenoviral infection 2. Ligneous conjitis 3. Gonococcal conj 4. Stevens Johnson synd

Differential diagnosis

Causes of chronic or recurrent conjunctivitis

1. 2. 3. 4. 5. 6. 7. Resistant organism Dacryocystitis, canaliculitis Ch blepharitis Rosacea keratoconjunctivitis Chlamydial infection Self inflicted Floppy eye lid synd.

Causes of follicular conjunctivitis

I. Simple follicular conjunctivitis 1. Viral a. Adenovirus with URT-I (pharyngoconjunctival fever) b. Inclusion conjunctivitis c. Epidemic K-conjitis (8,19,3,7) d. A herpetic conjitis e. Molluscum contagiosum 2. Ch simple conjitis 3. Poor hygiene, poor general health II. Trachoma III. Parinauds oculogenital syndrome IV. Hypersensitivity to topical drugs 1. Atropine, eserine, iodoxyuridine N.B folliculosis (allergic, error of refraction, herpes, adenovirus)

Causes of papillary conjunctivitis

1. 2. 3. 4. 5. 6. 7. Allergic conjunctivitis Bacterial infection Trachoma SLK Contact lens related Ch blepharitis Flobby lid syndrome

Conjunctival causes of Lymphadenopathy

1. 2. 3. 4. Viral infections Chlamydial infections Severe gonococcal infection Parinaud synd.

Differential diagnosis

Granulomatous subconj lesions

I. Infections 1. Parasitic 2. Mycotic 3. Leprosy II. Collagen diseases 1. Vasculitis 2. SLE 3. IBD 4. Rh A III. Sarcoidosis IV. Amyloidosis V. Histocytic granulomatous diseases 1. Juvenile xanthogranuloma 2. Subcutaneous xanthogranuloma 3. Sinus histocytosis 4. Histocytosis X 5. reticulohistocytoma

Causes of non-pigmented conjunctival lesions

1. 2. 3. 4. 5. 6. Papilloma (pedunculated/ sessile) Conj intraepith hyperplasia (CIS) SCC Epibulbar choriostoma (dermoid/ lipodermoid) Kaposi sarcoma Lymphoma

Causes of pigmented conjunctival lesions

1. 2. 3. 4. 5. Conj epith melanosis Cong ocular melanocytosis 1ry acquired melanosis Conj naevus Conj papilloma

DD of conjunctival melanoma
1. 2. 3. 4. 5. Large naevus Ciliary body melanoma Melanocytoma Pyogenic granuloma Pigmented conj carcinoma

Differential diagnosis

Causes of dry eye I. Lacrimal tissue

1. Atrophy, fibrosis a. KCS (pure) b. 1ry Sjogren synd (KCS+xerostomia) c. 2ry Sjogren = 1ry + RA/ JCA/ SLE/ SS/ psoriasis/ Hashimoto disease/ 1ry biliary cirrhosis 2. Destruction by a. Tumors b. Sarcoidosis c. Ch inflammation (pseudotumor/ dysthyroid..) 3. Absence of lacrimal gland a. Surgery for tumors b. Congenital (rare) 4. Blockage of ducts (severe conj scarring) II. Meibomian gland dysfunction III. SLK IV. Neurological lesions (Raily Day synd)

Causes of Mucin deficiency

1. --Vit A (xerophthalmia) 2. Conj scarring a. Steven Johnson synd b. OCP 3. Chemical burn 4. Irradiation 5. Trachoma

10

Differential diagnosis

Cornea Causes of Punctate epitheliopathy (PEE)

I. Superior 1. Vernal disease 2. SLK 3. Floppy lid synd 4. Poor CL fitting II. Interpalpebral 1. Dry eye 2. Corneal sensation 3. UVR exposure III. Inferior 1. Lower lid margin disease 2. Corneal exposure 3. Rosacea 4. Toxicity from drops 5. Self induced

Causes of corneal filaments KCS

1. 2. 3. 4. 5. 6. 7. 8. SLK Recurrent erosion synd Eye patching Exposure -- Corneal senstivity HZO Midbrain stroke Essential blepharospasm

Signs of previous ocular herpes infection Epith denderites Stromal keratitis / scarring Iris atrophy Irregular pupil Ant uveitis Inflammatory sterile keratitis
I. Stromal keratitis: Acute superficial and midstromal opacities with stroma oedema followed by vascularization and scarring II. Sclerosing keratitis:Perilimbal corneal thickening, opacification, lipid deposition and vascularization III. Furrowing:Peripheral corneal thinning +/- ulceration

11

Differential diagnosis

IV. Keratolysis:Peripheral ulcerative keratitis with edema, infiltration and sromal melting may lead to perforation

Peripheral corneal lesions

I. Non-inflammatory 1. Arcus senilis 2. Vogt white limbal girdle 3. Pseudogerotoxon of spring catarrh 4. Posterior embryotoxon of Axenfold-Reigers II. Inflammatory 1. Marginal keratitis 2. Rosacea keratitis 3. Chlamydial keratitis 4. Phlycenulosis 5. Exposure keratopathy 6. Sclerosing keratitis 7. Ant stromal keratitis III. Thinning not associated with RA, PAN or Wegner 1. Dellen 2. Terrien marginal degeneration 3. Moorens ulcer 4. Furrow degeneration 5. Fuchs superficial marginal keratitis 6. Pellucid marginal degeneration

Causes of peripheral ulcerative keratitis

I. Infectious 1. Bacterial 2. Viral 3. Staph marginal 4. Fungal II. Non infectious 1. Neurotrophic 2. Acne rosacea 3. Allergic 4. Mooren ulcer 5. Terrien marginal deg 6. Systemic a. Sjogren synd b. Graft vs host disease c. Pemphigoid d. RA, PAN, SLE e. Wegner granulomatosis

12

Differential diagnosis

Causes of non infectious corneal perforations (melts)

I. Post-infectious 1. Bacterial 2. Fungal 3. Viral: HSV, HZV II. Immunologic 1. Hypersensitivity (Staph) 2. Collagen vascular diseases 3. Rh A 4. Wegners granulomatosis 5. Sjogrens syndrome 6. Pemphigoid 7. Moorens ulceration III. Exposure 1. VII N palsy 2. Lid abnormality 3. Nocturnal lagophthalmos 4. Exophthalmos IV. Neurotrophic 1. V N palsy 2. Post HZV 3. Familial dysautonomia V. Traumatic 1. Chemical 2. Thermal VI. Dermatologic 1. Rosacea 2. Atopic dermatitis VII. Miscellaneous 1. Post cataract extraction 2. Vit A deficiency 3. Post irradiation 4. Topical anaesthetics abuse

Causes of interstitial keratitis

I. Infectious 1. Bacterial: Syphilis, Borrelia brugdorferi (lyme), Chlamydia trachomatis (LGV), TB, leprosy 2. Viral: HSV, HZV, EBV, rubella 3. Parasites: Leishmaniasis, oncocerca volvulous II. Non-infectious

13

Differential diagnosis

1. Reiter synd 2. Cogan synd

Causes of corneal hyposthesia

I. Bilateral 1. Aging 2. DM 3. Vit A deficiency 4. Leprosy 5. Contact lens wear 6. Topical drugs: B-blockers, topical anaesthetics 7. Corneal dystrophies a. Granular b. Lattice c. Macular 8. Fuchs congenital corneal anesthesia 9. Cavernous sinus lesions a. CS thrombosis b. Pit apoplexy c. Metastatic lesions II. Unilateral 1. Following viral keratitis: HSV, HZV 2. Healed ulcer of unknown cause 3. Following ophthalmic surgery a. Corneal transplantation b. LASIK, other refractive surgeries c. Cataract surgery d. Encircling buckle for RD e. Scatter photocoagulation adjacent to long ciliary N. f. Cuaterization of BM for ttt of bullous keratopathy g. Retrobulbar injection of alcohol h. Orbitotomy for deep orbital lesion 4. Acute and absolute glaucoma 5. Demyelinating diseases 6. Brain stem cerebrovascular accidents 7. Compression or lesion of 5th CN anywhere along its course a. C-P angle tumors: Acoustic neuroma, Meningioma b. Cavernous sinus lesions as above c. Superior orbital fissure lesions 1. Tolosa-Hunt syndrome 2. Mucormycosis 3. Sphenoid ridge meningioma 4. Blow out fractures

14

Differential diagnosis

8. Intraorbital FB 9. Botulinum toxin inection 10.Acanthamoeba keratitis

Corneal pigmentation
Type Iron Cause Keratoconus Old age Ptrygium Filtering bleb Hyphema Siderosis Chrysiasis Argyrosis Wilsons dis. PDS Name Fleischer ring Hudson Stahli line Stockers line Ferrys line Blood staining Location Epithelium

Stroma

Gold Silver Copper Melanin

Epith.& stroma Stoma & DM Kayser-Fleisher ring DM Krukenberg spindle endothelium

Causes of corneal edema

I. With normal endothelium 1. Persistent epith defect 2. ++ IOP: cong glaucoma, ACG II. 1ry endothelial disease 1. Endothelial dystrophies a. Fuchs endothelial dystrophy b. Post polymorphus dystrophy c. Cong hereditary endothelial dystrophy 2. Iridocorneal endothelial syndromes a. Iris naevus syndrome b. Chandlers syndrome c. Essential iris atrophy III. Mechanical trauma to endothelium 1. Cataract surgery 2. IOFB 3. Corneal trauma a. Chemical injury b. During birth c. Sensorimotor trigeminal neuropathy (surgery, tumors,) IV. Non-mechanical damage to the endothelium 1. Inflammatory: uveitis, graft rejection, Focal keratitis 2. Contact lens: hypoxia

15

Differential diagnosis

3. ++IOP

Causes of bullous keratopathy

1. 2. 3. 4. 5. 6. 7. Endophthalimitis Recurrent / chronic anterior uveitis, ICitis Endothelial dystrophy Trauma Chandlers synd Chemical toxicity Cong. Glaucoma

NB.Light scattering by edematous cornea does not occur until stroma swell>15%

Causes of cong corneal opacification= cloudy cornea in neonate

I. At birth 1. Infectious corneal ulcer 2. Forceps trauma 3. Congenital glaucoma 4. Congenital herediatry endothelial dystrophy 5. Congenital herediatry stromal dystrophy 6. Posterior polymorphus dystrophy 7. Sclerocornea 8. Congenital syphilis / rubella 9. Peters anomaly 10.Limbal dermoid (Goldenhars syndrome) 11.Congenital corneal staphyloma II. Early neonatal period 1. Mucopolysaccaridosis a. Hurlers b. Sheie 2. Fabrys disease 3. Mucolipidosis 2,4 4. Cystinosis 5. Exposure keratopathy (lid anomaly) 6. Dehydration

DD of posterior scleritis
1. 2. 3. 4. 5. 6. Optic neuritis Rhegmatogenous retinal detachment Choroidal tumour Orbital inflammatory disease or mass Uveal effusion synd Harada disease

16

Differential diagnosis

Mucopolysaccharidoses
Type MPS1-H MPS1-S MPS 2 MPS 3 MPS 4 MPS 6 Name Hurler Scheie Hunter Sanfilippo Morquio Marolteaux-Lamy + C.deposit R.deg +++ + Op A +

17

Differential diagnosis

Uvea Causes of iris mamillations

1. 2. 3. 4. Ocular melanocytosis Neurofibromatosis-1 Axenfold Reigers anomaly Peters anomaly

DD of heterochromia iridis
I. Hypochromia 1. Congenital 2. Horner synd especially congenital 3. Fuchs uveitis II. Hyperchromia 1. Naevus of Ota 2. Ocular siderosis 3. Diffuse iris naevus or melanoma 4. Sturge Weber synd 5. Unilateral use of latanoprost 6. Fuchs uveitis

Causes of rubeosis irides

I. Vascular 1. CRV-O, branch RVO 2. CRA-O 3. Carotid occlusive disease II. Ocular disease 1. Sympathetic ophthalmia 2. VKH 3. RD 4. Coats disease 5. 2ry glaucoma III. Surgery and radiotherapy 1. RD surgery 2. Radiation IV. Systemic disease 1. DM 2. Sickle cell disease V. Neoplastic 1. Retinoblastoma 2. Nelanoma of choroids, iris 3. Metastatic carcinoma VI. Trauma

18

Differential diagnosis

Causes or iris nodules

I. Congenital 1. Down syndrome ( Brushfield spot) 2. Melanocytosis II. Traumatic 1. Implantation cyst 2. Retained FB III. Inflammatory 1. Iridocyclitis (Koeppe, Busacca) 2. Fungal endophthalmitis 3. Leprosy (iris pearls) IV. Neoplastic 1. Iris naevus, tapioca melanoma 2. Iris melanoma 3. Leiomyoma 4. JXG 5. Retinoblastoma 6. Leukaemia 7. Metastatic carcinoma V. Miscellaneous 1. Iris freckle 2. Neurofibroma (Leisch) 3. Cogan Reese syndrome = iris naevus syndrome 4. Iris pigment epithelial cyst 5. Iris pigment epithelial proliferation

Causes of prolonged hypotony

1. 2. 3. 4. 5. 6. GFS Ch ant uveitis Choroidal detachment Ischaemic ocular synd Penetrating trauma cyclodialysis

HLA
Acute anterior uveitis: HLA-27B, B8. Ankylosing spondylitis: HLA-B27, B7 Rheumatoid A: HLA-DR4 Behcet disease: HLA-B51 Reiter syndrome: HLA-B27 Bird shot retinopathy: HLA-A29 Multiple sclerosis: HLA-DR2 Ocular pemphigoid: HLA-B12,DQw7

19

Differential diagnosis

POHS: HLA-B7, DR2 Sympathetic ophthalmia: HLA-A11, DR4, Dw53. VKH: DR4, Dw53, DQw3 Causes of chronic non infective uveitis
I. With arthritis 1. Ankylosing spondylitis 2. Psoriatic arthritis 3. JCA II. With systemic diseases 1. Sarcoidosis 2. Behcet disease 3. VKH III. Idiopathic specific uveitis 1. Fuchs uveitis 2. Intermediate uveitis 3. Juvenile ch uveitis IV. Rare idiopathic specific uveitis 1. Sympathetic 2. Serpigenous choroidopathy 3. Bird shot retinochoroidopathy 4. Glaucomatocyclitic crises 5. Eales disease

Causes of childhood uveitis

I. Anterior uveitis 1. JCA 2. Ankylosing spondylitis 3. Behcet disease 4. Sarcoidosis 5. Traumatic ant uveitis 6. Crohns disease 7. White uveitis ( 4-16yrs, >, triad of: band keratopathy, PSC,
extensive post synechiae; look for macular cyst, investigations for syphilis, chest x-ray)

II. Intermediate uveitis 1. Pars planitis III. Post uveitis 1. Toxoplasmosis 2. Toxocariasis 3. Sympathetic ophthalmia 4. Bacterial/ viral infections

20

Differential diagnosis

Uveo-meningeal syndromes
I. Idiopathic 1. MS II. Infectious 1. Bacterial: syphilis, lyme, TB 2. Viral: CMV, HSV, HZV 3. Fungal: cryptococci, candida 4. Protozoal: toxoplasmosis III. Inflammatory 1. VKH 2. Behcet 3. Sarcoidosis 4. APMPPE 5. PAN IV. Neoplastic 1. Reticulum cell sarcoma 2. Lymphoma 3. Metastatic neoplasm

Causes of graulomatous uveitis

1. 2. 3. 4. 5. 6. Sarcoidosis TB Syphilis Fungal Parasitic Sympathetic

Causes of uveitis with hyphema

HLA B 27 uveitis Post op endophthalmitis UGH-syndrome VZV HSV Behcet disease Fuchs uveitis

Causes of uveitis with ++ IOP

HSV HZV Posner Schlossmann syndrome

21

Differential diagnosis

Sarcoidosis Fuchs uveitis

Uveitis with diffusely distributed KPs

HSV HZV Sarcoidosis Fuchs uveitis Toxoplasmosis

Causes of cannon balls in the vitreous

1. 2. 3. 4. 5. 6. Candidiasis Intermediate uveitis Sarcoidosis Lyme disease Whipple disease Endophytic retinoblastoma

Causes of viral uveitis with chorioretinitis

1. 2. 3. 4. 5. 6. 7. 8. 9. Adenovirus HSV HZV AIDS CMV EBV Influenza Neasles Mumps

Causes of non granulomatous choroiditis

1. APMPPE 2. A-RPEitis 3. Geographic peripapillary choroiditis

DD of Behcet disease
1. 2. 3. 4. 5. Sarcoidosis Rieter synd Viral whipple disease Crohns disease Collagen disease

Sexually transmitted diseases with ocular manifestations

1. AIDS 2. Syphilis

22

Differential diagnosis

3. Chlamydial infections 4. gonorrohea

Immunocompromised patients
1. 2. 3. 4. 5. 6. 7. Chemotherapy Long-term immunosuppressive therapy Long-term use of steroids AIDS Malnutrition DM Elderly

Multifocal chroidopathies
Multifocal infectious choroidopathies POHS Ocular coccidioidomycosis Cryptococcal choroiditis Pneumocystis carinii choroiditis Tuberculous choroiditis Syphilitic choroiditis Multifocal inflammatory choroidopathies Sarcoid choroidopathy VKH syndrome Sympathetic ophthalmia Bird shot PIC Multifocal choroiditis and panuveitis Multifocal Vascular choroidopathies AMPPPE SLE Pre-eclampsia and multifocal ischemic choroidopathy Multifocal neoplastic choroidopathies Choroidal metastasis Lymphomatous choroidopathy Leukaemic choroidopathy Bilateral diffuse uveal melanocytic proliferation Others MEWDS ARPE RMC Serpiginous choroiditis

23

Differential diagnosis

Causes of posterior uveitis

Retinitis + vitritis Regional Toxoplasmosis Toxocariasis CMV-retinitis Neoplastic Multifocal Syphilis, TB ARN, EBV, rubella Candidiasis Bird shot APMPPE POHS TB, lyme Serpigineous choroiditis Behcet SLE HIV Diffuse Endophthalmitis Toxocariasis

Retinitis without vitritis Choroiditis

VKH Oncocerciasis sympathetic

vascultitis

DD of retinitis Focal
a. Associated with vitritis i. Arteritis 1. ARN 2. Behcet ii. Choroiditis 1. Toxoplasmosis 2. Toxocariasis 3. Fungal b. Macular i. Autoimmune: Behcet, SLE ii. Infection: DUSEN iii. Immunocompromised: CMV, toxoplasmosis, POHS iv. Masquerades: leukaemia, radiation retinopathy c. Peripheral v. Autoimmune: Behcet, sarcoidosis vi. Infection: ARN vii. Immunocompromised: CMV, toxoplasmosis, POHS viii. Masquerades: leukaemia, radiation retinopathy

Multifocal
Autoimmune: Behcet, sarcoidosis Infection: ARN, DUSN

24

Differential diagnosis

Immunocompromised: CMV, toxoplasmosis, POHS, hepatitis C Masquerades: leukaemia, radiation retinopathy

Causes of infectious retinitis

Viral HSV VZV CMV Rift valley fever virus SSPE AIDS Bacterial retinitis Fungal retinitis Parasitic retinitis

Causes of retinal vasculitis

I. Periphlebitis 1. Sarcoidosis 2. Behcet 3. CMV retinitis 4. ARN 5. Intermidate uveitis 6. MS 7. TB 8. Syphilis 9. Toxoplasmosis 10.Viral retinitis 11.Lyme disease 12.Cat scratch disease 13.Eals disease 14.Angeitis de rama 15.idiopathic II. Periarteritis 1. SLE 2. Dermatomyositis 3. PAN 4. Wegner granulomatosis 5. GCA 6. IBD 7. Polyarteritis

25

Differential diagnosis

Io tumors

Common tumors
Retina
1. 2. 3. 4. Retinoblastoma Astrocytoma (tuberous sclerosis) Haemangioma (capillary/ caverneous/ racemose) RPE tumors a. CHRPE (typical; solitary, grouped/ atypical multiple b. Combined hamartoma of RPE and retina

Choroid
1. 2. 3. 4. 5. 6. 7. Melanoma Naevus Haemangioma (circumscribed/ diffuse = Sturge Weber) Metastatic Osseous carcinoma Lymphoma melanocytoma

Causes of leukocoria
1. Retinoblastoma 2. Congenital cataract 3. Coats disease 4. ROP 5. Toxocariasis 6. PHPV 7. Retinal dysplasia 8. Inflammatory cyclitic membrane 9. Incontinenta pimenti 10.Retinal astrocytoma

DD of iris melanoma
1. 2. 3. 4. 5. 6. Iris naevus CB melanoma Metastases Primary iris cyst Adenoma of iris pigment epithelium leiomyoma

DD of CB melanoma
1. Medulloepithelioma (diktyoma)

26

Differential diagnosis

2. Uveal effusion syndrome 3. Congenital epithlial iridociliary cysts 4. Other CB tumours a. Metastases b. Adenocarcinoma c. Cystic adenoma d. Leiomyoma e. Haemangioma

Tumors of the macula

Choroidal melanoma Retinoblastoma RPE tumors Combined hamartoma of RPE and retina Adenoma of RPE Adenocarcinoma of RPE 1ry intraocular non-Hodgkin lymphoma

27

Differential diagnosis

retina Vascular sclerosis

A. B. C. D. Vascular reflex i. Copper wire ii. Silver wire Changes in course and diameter i. Turtousity, attenuation, irregularity Sheathing A-V crossing changes i. Nicking (Gunns sign) = obscuration at crossing ii. Deflection 1. Vertical (Salus sign) 2. Lateral (s, z) iii. Banking = distension of the vein distal to crossing

Causes of changes in vascular caliber

I. Attenuation of A 1. HTN 2. RAO 3. Severe diffuse retinopathy 4. Rare syst synd a. Batten-Vogt b. Zellwger II. Dialatation + tortuosity of A&V 1. Nanophthalmos 2. ROP+ 3. Capillary haemangioma 4. Racemose haemangioma 5. Moroteaux-Lamy synd III. Dialatation +\- tortuosity of A&V 1. Incepient CRVO 2. prePDR 3. Hyperviscosity 4. Ocular Ischaemic synd 5. Carotid cavernous fistula 6. Hereditary venous arrosariamiento 7. Primary antiphospholipid AB 8. ++ intraorbital pressure 9. Fabry disease 10.mannosidosis

28

Differential diagnosis

Causes of vitreous hemorrhage

1. Trauma 2. Retinal disease (retinitis, RD) 3. Vascular disease of retina (CRV thrombosis, Eales disease, retinopathy especially diabetic 4. Blood disease (anaemia, leukaemia, purpura) 5. IO tumors

Causes of preretinal hemorrhage

1. 2. 3. 4. 5. 6. Proliferative retinopathies Retinal arterial macroaneurism Trauma Tyrson synd=subarachnoid hge Valsalva retinopathy Shaken baby synd

Causes of subretinal hemorrhage

1. 2. 3. 4. 5. 1. 2. 3. 4. CNV Rupture retinal artery macroaneurism Coats disease Sickle cell anemia Blunt trauma

Causes of flame shaped hemorrhage

RVO HTN retinopathy Background DR ONH disease a. Acute papilledema b. AION 5. Retinal periphlebitis (CMV-retinitis)

Causes of retinal hemorrhage I. Local

1. 2. 3. 4. Trauma Sudden IOP (surgery, trauma, perforated corneal ulcer) Arterial hyperemia (retinitis, choroiditis) Venous congestion (CRV thrombosis, papilledema, papillitis)

II. General 1. Vascular disease (arterial sclerosis, vascular retinopathy) 2. Blood disease 3. Severe straining

29

Differential diagnosis

Causes of disc hemorrhage

1. 2. 3. 4. 5. 6. 7. 8. 9. Acute papilloedema AION Papillitis Diabetic papillopathy Ch glaucoma Infiltrative op neuropathy After op nerve sheath decompression PVD ONH drusen

Vascular anomalies of the macula

Arterial macroaneurysms Retinal macrovessel Coats disease Parafoveal telagiectasia Retinal capillary hemangiomas Retinal cavernous hemangiomas A-V communications

Causes of subretinal neovascularization

I. Degenerative 1. AMD 2. High myopia 3. Angioid streaks 4. Inappropriate laser photocoagulation 5. Traumatic choroidal rupture II. Inflammatory 1. POHS 2. Rubella retinopathy 3. PIC 4. Serpigineous choroidopathy 5. Bird shot retinochoroidopathy 6. Multifocal choroiditis with panuveitis III. Hereditary 1. Sorsby pseudoinflammatory dystrophy 2. Bests disease 3. Op disc drusen IV. Miscellaneous 1. Choroidal naevus 2. Idiopathic

30

Differential diagnosis

Causes of macular CNV

I. Degenerative 1. ARMD 2. High myopia 3. Angioid streaks II. Hereditary 1. Sorsby dystrophy 2. Best disease 3. OD drusen III. Traumatic 1. Inapropriate laser photocoagulation 2. Traumatic choroidal rupture IV. malignant V. Inflammatory 1. POHS 2. Inner punctate choroidopathy 3. Serpigenous choroidopathy 4. Retinopatia en perdigonada 5. Multifocal choriditis with panuveitis 6. Rubella retinopathy VI. Others 1. Nevo coroideo 2. Idiopathic

Causes of neovascularization
I. Central 1. PDR 2. Old RVO 3. Retinal vasculitis 4. RAO 5. Ocular ischaemic synd 6. Carotid-cavernous fistula 7. Radiation retinopathy II. Peripheral 1. ROP 2. Sickle cell retinopathy 3. Eals disease 4. Sarcoidosis 5. Intermediate uveitis 6. Ch myeloid leukaemia 7. Familial exudative vireoretinopathy 8. Incontinentia pigmenti

31

Differential diagnosis

DD of peripheral retinal NV
I. Vascular disease + ischaemia 1. PDR 2. B-RVO 3. B-RAO 4. Carotid-Caverneous fistula 5. Sickling Hb pathies 6. Eales disease 7. Retinal embolization 8. ROP 9. FEVR 10.Hyperviscosity synd 11.Aortic arch synd/ OIS 12.IRVAN II. Inflammatory dis+ possible ischaemia 1. Sarcoidosis 2. Ret vasculitis eg SLE 3. Uveitis eg pplanitis 4. Bird shot CH-R pathy 5. Toxoplasmosis 6. M sclerosis III. Miscellaneous 1. Incontinentia pigmenti 2. Long standing RD 3. Ch melanoma 4. RP 5. Retinoschesis

Causes of cotton wool spots

1. Diabetic retinopathy 2. Microembolic RAO Precapillary arteriolar obstruction 3. RVO 4. Systemic HTN 5. Ocular ischaemic synd 6. Cardiac embolic disease 7. Vasculitis 8. Collagen vascular disease 9. Sickle cell retinopathy 10.Leukemia 11.HIV microvasculopathy 12.Radiation retinopathy 13.Anti phosopholipid AB 14. Purtscher retinopathy 15.Acute pancreatitis

32

Differential diagnosis

Causes of macular edema

I. Iatrogenic 1. Cataract surgery (Irvine-Gass) 2. YAG laser capsulotomy 3. Laser photocoagulation 4. RD surgery 5. Cryotherapy 6. Topical epinephrine 2% in aphakia II. Ch IO inflammation 1. Ch iridocyclitis 2. Intermediate uveitis 3. Bird shot retinochoroidopathy 4. Panuveitis 5. Infectious endophthalmitis III. Retinal vascular disease 1. DM 2. RVO 3. Malignant hypertension 4. Toxaemia of pregnancy IV. 2ry to other maculopathies 1. Neovascular 2. Preretinal macular fibrfosis 3. VM traction syndrome V. Associated with hereditary dystrophies 1. RP 2. Gyrate atrophy VI. Miscellaneous 1. Nicotinic acid (high dose) 2. Familial dominant

Causes of cystoid macular oedema

I. With retinal vascular leakage 1. Diabetic retinopathy 2. Branch VO 3. Pseudophakic or aphakic CMO 4. Intermediate uveitis 5. Idiopathic retinal telangiectasia 6. Vitreomacular tractional synd 7. Dominantly inherited CMO II. Without retinal vascular leakage 1. Some ..retinitis pigmentosa 2. Macular hole 3. Nicotinic acid maculopathy 4. CNV

33

Differential diagnosis

Causes of macular star

1. 2. 3. 4. Hypertension Papilloedema Neuroretinitis Capillary angioma

Causes of crystalline maculopathy

I. Drug induced 1. Tamoxifen 2. Cantataxina 3. Talc 4. Methoxyfluorane II. Metabolic 1. Cystinosis 2. Primary oxalosis type 1 III. Others 1. Bietti dystrophy 2. Sjogren-Larsson synd

Pediatric macular diseases

I. Congenital macular diseases 1. Foveal hypoplasia 2. Macular dysplasia 3. Chorioretinal colobomas 4. Chorioretinal scars 5. Combined hamartoma of retina and RPE II. Acquired without systemic disorders 1. Juvenile retinoschisis 2. Stargardts disease 3. Progressive cone dystrophy 4. Vitelliform dystrophy 5. Pattern dystrophy of RPE 6. Subretinal neovascularization 7. Macular ectopia 8. Myopic degeneration III. Acquired with systemic disorders 1. Batten disease 2. Tay-Sachs disease 3. Sandhoffs disease 4. Neimann-Pick disease 5. Sickle cell disease 6. Olivopontocerebellar atrophy 7. Shaken baby syndrome 8. Sjogren-Larsson syndrome

34

Differential diagnosis

Causes of vascular traction

1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. PDR Falciform proliferative retinopathy ROP Exudative familial vitreoretinopathy Toxocara peripheral granuloma Incontinentia pigmenti Comined hamartoma of retina and RPE Severe anaemia Leukaemia Dysproteinaemias HIV retinopathy Bacterial endocarditis Diabetes Old branch RV-O Retinal arterial macroaneurism Radiation retinopathy Retinal telangiectasia

Causes of Roth spots

Causes of hard exudates/ circinate ring

Causes of subretinal exuadates

1. Chronic extravasation from neovascular membrane 2. Coats disease 3. Toxocara canis

Causes of atrophic maculopathies

I. Non-hereditary 1. Dry AMD 2. Myopic maculopathy II. Hereditary 1. Stargardt disease (end stage) 2. Central areolar choroidal dystrophy 3. Sorsby macular dystrophy 4. Best disease (end stage) 5. North Carolina dystrophy (end stage)

Multiple white dot syndromes

1. 2. 3. 4. 5. 6. MEWDS APMPPE Serpiginous choroidopathy Birdshot chorioretinopathy Punctate inner choroidopathy Multifocal choroiditis with panuveitis

35

Differential diagnosis

Dystrophy of RPE
1. 2. 3. 4. 5. 6. Best bitelliform macular dystrophy Stargardt macular dystrophy, Fundus flavimaculatus Familial dominant drusen Sorsby pseudoinflammatory macular dystrophy North Carolina macular dystrophy Pattern dystrophy (Adult vitilliform, butterfly)

Choroidal dystrophy
1. Choroideremia 2. Gyrate atrophy 3. Central areolar choroidal dystrophy

Vitreoretinal degeneration
1. 2. 3. 4. Stickler syndrome Cong retinoschisis Favre-Goldmann syndrome Familial exudative VR

Causes of night blindness

A. B. General ocular cause 1. Peripheral cataract 2. Advanced glaucoma Inherited degeneration of retina and choroid Progressive 1. Gyrate choroidal atrophy 2. Diffuse choriocapillaritis A 3. Degenerative myopia 4. RP (classical, variants, syndromes) 5. Leber congenital amaurosis 6. Cone rod dystrophy 7. Goldmann-Favre vireoretinal dystrophy Stationary 1. Nougaret disease 2. Riggs disease 3. Congenital nyctalopia with myopia 4. Oguchi disease 5. Fundus albipunctatus Acquired disease of retina and choroids 1. --vit A 2. Laser photocoagulation 3. Drug toxicity (pheonthiazine)

C.

36

Differential diagnosis

DD of bulls eye maculopathy

Central foveal hyperpigmentation surrounded by oval depigmented zone outlined by a ring of hyperpigmentation (FA: depigmentation RPE window defect)

1. 2. 3. 4. 5. 6.

Chloroquine maculopathy Cone dystrophy Advanced stargardt disease Inverse retinitis pigmentosa Bardet Biedle Benign concentric annular macular dystrophy 7. Fenestrated sheen dystrophy 8. Batten disease

Causes of cherry-red spot

1. CRA-O 2. Infantile amaurotic family idiocy = Tay-Sachs disease = Gm2 gangliosidosis type 1 3. Niemann-Pick disease A..severe early CNS deterioration B..normal CNS function C..moderate CNS involvement D..late onset severe CNS involvement 4. Sandhoff disease =Gm2 gangliosidosis type 2 5. Generalized gangliosidosis=Gm1 gangliosidosis type 1 6. Cherry-red spot myoclonus synd=Sialidosis 1&2 7. commotion retina 8. quinine poisoning 9. macular hole, hemorrhage, cyst

Causes of folds and streaks in the fundus

1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. Chorioretinal folds Lacquer cracks Angioid streaks Choroidal rupture Pigment demarcation line in RD Idiopathic..hyperopia Orbital disease Retrobulbar mass Thyroid ophthalmopathy Choroidal tumour Posterior scleritis

Causes of choroidal folds

37

Differential diagnosis

7. Ocular hypotony

Causes of exudative RD
I. Choroidal tumours 1. Primary 2. Metastatic II. IO inflammation 1. Harada disease 2. Posterior scleritis 3. Necrosing retinitis III. Exudation of suretinal BV 1. CNV 2. Retinal telangiectasia IV. Systemic 1. HTN 2. Toxaemia of pregnancy 3. Hypoproteinaemia V. Iatrogenic 1. RD surgery 2. Extensive photocoagulation VI. Others 1. CSR 2. Derrame uveal syndrome

Systemic associations of angioid streaks ( PEPSI)

1. 2. 3. 4. 5. PXE Ehlers Danlos synd Paget disease Sickle cell disease and thalassaemia idiopathic

Causes of pigmented fundus lesions

1. Choroidal naevus 2. Naevus of Ota 3. CHRPE 4. Choroidal melanoma 5. Melanocytosis of ONH 6. Fuchs spot 7. RPE hyperplasia 8. RP 9. RP syndromes 10.Diffuse granular pigment clumping 11.Drugs (chloroquine) 12.Clumping over sclerosed vessels 13.Pigmented paravenous retinochoroidal atrophy

38

Differential diagnosis

14.Grouped pigmentation of the retina

Solitary fundus lesion

I. Dark 1. 2. 3. 4. 5. II. Pale 1. 2. 3. 4. 5. 6. 7. Old chorioretinitis Idiopathic chorioretinal atrophy Coloboma of retina and choroid Cong albinotic spots Choroidal metastatic tumors Retinal astrocytoma Early retinoblastoma Cong RPE hypertrophy Choroidal naevus Choroidal melanoma RPE hamartoma Black sunburst spot in SC retinopathy

White spots in the fundus

I. Inner retinal layers 1. POHS: focal opacity along BVs 2. Myelinated nerve fibres: flat, fan-shaped 3. Cotton wool spots: focal, poorly defined 4. Retinoblastoma: mulberry white mass 5. Astrocytic hamartoma II. Choroidal mass 1. Amelanotic melanoma 2. Choroidal metastasis III. Outer retina & inner choroid 1. MEWDS 2. APMPPE 3. Birdshot retinochoroidopathy 4. RMC 5. Fundus flavimaculatus (Stargardt disease) 6. Dominant drusen 7. Hard exudates 8. Fundus albipunctatus 9. Bests disease IV. Others 1. ARN 2. CMV retinitis 3. HSV retinitis 4. AIDS 5. Rift valley fever

39

Differential diagnosis

6. Endogenous fungal infection

Causes of multiple yellow flecks

I. Non-Hereditary 1. Drusen: hard, soft, basal laminar 2. Type II mesangiocapillary membranoproliferative GNitis II. Hereditary 1. Familial dominant drusen 2. Malattia levatinese 3. Fundus flavimaculatus 4. Fundus albipunctatus 5. Retinitis punctata albescence 6. Pattern dystrophy 7. Benign flecked retina syndrome 8. Alport syndrome 9. North Carolina macular dystrophy

Diffuse pigment clumping

I. Non-Hereditary 1. Age related honey comb degeneration 2. Advanced chloroquine toxicity 3. Related to RD 4. Grouped cong RPE hypertrophy 5. Reubella retinopathy 6. Congenital syphilis II. Hereditary 1. Typical retinitis pigmentosa 2. Atypical retinitis pigmentosa + associations 3. Female carrier of choroideremia 4. Angioid streaks

Causes of Generalized white fundus

I. Non-hereditary 1. Extensive retinal nerve fiber layer demyelination 2. High myopia 3. Acute retinal ischaemia a. BRA-O, CRA-O b. Ophthalmic A occlusion 4. Commotion retinae 5. Large coloboma of retina and choroids II. Hereditary 1. Albinism 2. Choroideremia 3. Gyrate atrophy 4. Diffuse choroidal atrophy

40

Differential diagnosis

5. Progressive bifocal chorioretinal atrophy

41

Differential diagnosis

neuorophthalmology Causes of big blind spot syndrome

I. With visible op n lesion that explain blind spot enalrgement 1. Papilledema 2. Op disc swelling 3. Papillitis 4. Medullated nerve fibers 5. Coloboma of optic disc 6. Drusen of optic disc 7. Glaucoma 8. Progressive myopia with a temporal crescent II. Without obvious abnormality that explains blind spot enlarge. 1. Acute blind spot enlargement a. Acute idiopathic blind spot enlargement b. MEWDS c. Juxtapapillary choroiditis d. Peripapillary serous RD e. Choroidal folds 2. Chronic blind spot enlargement a. Chronic idiopathic blind spot enlargement b. Dominant optic atrophy c. Peripapillary pigmentary retinal degeneration

Causes of bilateral op disc elevation

I. Papilloedema II. Buried op disc drusen III. Miscellaneous causes 1. Compressive thyroid op neuropathy 2. Diabetic papillopathy 3. Methanol toxicity 4. Bilateral papillitis 5. Bilat simultaneous arteritic AION 6. venous drainage

Causes of increased ICT

IV. Space occupying lesions 1. Tumors 2. Hemorrhage V. Pseudotumor cerebri VI. Infections: Meningitis, Encephalitis

42

Differential diagnosis

VII. Toxic and Metabolic 1. Lead poisoning 2. Ch hipervitaminosis A 3. Renal failure 4. Hypercapnia VIII. Developmental 1. Aqueduct stenois 2. Craniodysostoses 3. AV malformations IX. Iatrogenic 1. Radical neck surgery 2. tetracyclines

Causes of unilateral ON swelling

I. Ocular
1. Papillitis, neuroretinitis

2. AION 3. ON drusen 4. Papillophlebitis 5. CRV-O 6. CRA-O 7. Hypotony after surgery, trauma 8. Ch ant uveitis, pars planitis 9. Leber heridiatary op neuropathy II. Orbital 1. ON tumors: glioma, meningioma, metastasis 2. ON trauma 3. Ophthalmic A aneurism 4. Orbital tumors, 5. Orbital cellulitis, abscess III. Intracranial 1. Post fossa tumor 2. Pseudotumor cerebri 3. Brain abscess 4. Subarachnoid hemorrhage 5. Early caverneous sinus thrombosis 6. Carotid caverneous fistula IV. True papilledema with controlateral 1. Op atrophy 2. Glaucoma 3. High myopia

43

Differential diagnosis

Causes of compressive op neuropathy

I. Intraorbital 1. Op n glioma 2. Op n meningioma 3. Thyroid ophthalmopathy 4. Orbital tumors 5. Orbital cellulitis II. Intracanalicular 1. Paget disease 2. Fibrous dysplasia 3. Osteoporosis III. Intracranial 1. Meningioma 2. Pit adenoma IV. Choroidal osteoma

Infiltrative disc lesions

I. Neoplastic 1. Adjacent tumors a. Retinoblastoma b. Choroidal melanoma 2. Systemic malignancies a. Leukemia b. Lymphoma c. Metastatic tumors II. Granulomatous and inflammatory 1. Sarcoid granuloma 2. Toxocara 3. CMV

Causes of Parinaud synd

I. In children 1. Aqueduct stenosis 2. Meningitis 3. pinealoma II. In young adults 1. Demylination 2. Trauma III. AV malformations IV. In old 1. Mesencephalic vascular accidents 2. Tumours affecting the periaqueductal grey matter 3. Giant aneurisms in posterior fossa

44

Differential diagnosis

Causes of 1ry op atrophy

I. Following retrobulbar neuritis II. Compressive op neuropathy III. Toxic op neuropathies 1. Methanol 2. Ethambutol 3. INH 4. Amiodarone, streptomycin, chlorpropamide IV. Nutricional deficiency 1. Thiamine: tobacco-alcohol amblyopia, beriberi 2. Vit B12: pernicious anemia 3. Niacin: pellagra V. Traumatic op neuropathies 1. op N transection 2. Retrobulbar hemorrhage VI. Hereditary op atrophies

Causes of Poor vision with normal fundus

I. With nomal eye movement In children

1. Refractive errors 2. Amblyopia (check refraction, look for squint) 3. Non organic V loss 4. Delayed visual maturation 5. Incipient ret dystrophy a. Cone dystrophy b. Stargardt dystrophy 6. Cortical visual alterations II. With nomal eye movement In adults 1. Retrobulbar neuritis (check pupillary reaction, colour vision) 2. Nutritional amblyopia (check colour vision) 3. Cancer associtated retinopathy III. Without nomal eye movement In children 1. Leber congenital amaurosis (rotatory eye movements, high
hyperopia, eye poking) 2. Achromatopsia (nystagmus, photophobia) 3. X-linked recessive congenital stationary night blindness (nystagmus,nyctalopia, myopia)

45

Differential diagnosis

miscellaneous Causes of increased intraocular calcium density

I. Recent trauma; possible bone IOFB II. Old trauma or inflammation 1. Calcified cataract 2. Phithis bulbi 3. Massive retinal gliosis III. Without previous trauma 1. Retinoblastoma (infant, child) 2. Op N drusen (pseudopapilledema) 3. Episcleral osseous choriostoma (ant. Subconj, child) 4. Choroidal osteoma (post bilat subretinal) 5. Dystrophic scleral plaques (ant to recti, elderly)

Ocular manifestations of renal diseases

1. 2. 3. 4. 5. 6. 7. Lid edema Blepharoconjuctivitis Renal retinopathy Uraemic amourosis Tubulo-interstitial nephritis, IgA GNitis ?? Wilms tumor associated with aniridia Wegner granulomatosis

Ocular manifestations of blood diseases

RBCs 1. Polycythaemia a. Lid, conj: engorged BV b. Fundus: dilated tortuous BN, Cyanotic background, CRV thrombosis 2. Anaemia a. Conj: pallor b. Fundus:?? c. Cataract due to disturbed metabolism d. Hemorrhage in conj, lid, orbit WBCs-Leukaemia Adenxa: leukaemic infiltrates, hemorrhage, proptosis Fundus?? Platelets-Thrombocytopenic purpura Hemorrhage: lid, conj, lacrimal gland (hematidrosis), retina Reticulosis: lid, conj, lacrimal gland, orbit

46

Differential diagnosis

Diminution of vision
I. Transient visual loss-Few seconds 1. Papilloedema II. Transient visual loss-Few minutes 1. Amaurosis fugax 2. Vertebrobasilar A insufficiency III. Transient visual loss-10 to 60 minutes 1. migrane 2. Impending CRV-O 3. ION 4. Ocular Ischaemic syndrome 5. Glaucoma 6. Sudden change in Bl Pr 7. CNS lesion 8. Optic disc drusen 9. GCA IV. Sudden Painless Visual Loss < 24 hrs 1. RAO / RVO 2. Commotio retinae 3. ION / Optic neuritis 4. RD / Vit hge 5. Other retinal dis 6. CNSstroke 7. Methanol poisoning V. Diminution of vision in few days 1. corneal ulcer 2. iritis and choroiditis 3. RD, retinopathy 4. op neuritis VI. Gradual Painless Visual Loss 1. Senile cataract 2. AMD 3. OAG 4. Refractive error especially progressive myopia 5. Op neuropathy, primary optic atrophy 6. retinitis pigmentosa 7. amblyopia ex anopsia 8. DR 9. Ch corneal dis dystrophy

Causes of sudden complete loss of vision

1. CRA-O 2. Amaurosis fugax

47 3. Trauma: Rupture globe, Op n avulsion

Differential diagnosis

4. Hysteria 5. Malingering 6. Cortical blindness

Causes of transient blackout of vision (amaurosis fugax)

I. Hysteria II. Cerebrovascular insufficiency 1. Unilat occlusive carotid disease 2. Posttraumatic A/Ch arterial occlusion 3. Fibromuscular hyperplasia 4. Cong/ aquired A-V malformations 5. Arterial aneurysms III. Hypotension of the fundus 1. Cardiac arrhythmia 2. Papilledema 3. ++ ICT 4. Orbital vascular insufficiency with GCA 5. Impending vascular occlusion e.g CRA spasm 6. ++ venous pressure e g impending CRV-O, glaucoma IV. Ophthalmic migraine V. Raynauds disease VI. Atherosclerosis, HTN, HTN crisis VII. Uraemic amaurosis VIII. Hematologic causes 1. Polycythemia 2. Sickle cell disease 3. Thrombocytopenia 4. Multiple myeloma IX. Quinie poisoning X. Large vitreous floaters XI. MS + exercise (Uhthoff phenomenon)

Causes of burning sensation

I. More common 1. Blepharitis, Meibomianitis 2. Dry eye syndrome 3. Conjunctivitis: Infectious, Allergic, Mechanical, chemical II. Less common 1. Corneal problems..+fl 2. Inflammed ptrygium, pingueula 3. Episcleritis 4. SLK 5. Toxicity: Medications, Contact lens fluid, Make up

48

Differential diagnosis

Causes of shallow AC
I. Small globe 1. Hyperopia 2. Nanophthalmos 3. Microphthalomos II. Small cornea 1. Microcornea 2. Cornea plana III. Lens 1. Inumescent cataract 2. Ant dislocation IV. Post traumatic 1. Ciclodialysis 2. Leaking wounds V. Post operative 1. Leaking wound 2. Pupillary block by AC-IOL 3. Expansile gas in vit 4. Choroidal detachement after PRP VI. Others 1. Inflammatory pupillary block with iris bombe 2. CB tumours, cysts 3. Peter anomaly 4. iridoschesis

Causes of very deep AC

I. Large globe 1. High myopia 2. Buphthalmos II. Large cornea 1. Advance KC 2. Keratoglobus 3. Megalocornea III. Lens abnormality 1. Aphakia 2. Pseudophakia 3. Ectopia lentis IV. Post traumatic 1. Angle recession 2. Posterior rupture of globe V. PDS

Causes of hyphemia
I. Trauma II. Surgery III. Iritis 1. HSV, HZV IV. Blood dyscrayasis V. Ghost cells with vit hge VI. Anomalies of iris & angle 1. Rubeosis 2. Xanthogranuloma 3. Fuchs HU 4. Spontaneous

49

Differential diagnosis

Additional DD Corneal neovascularization

I. contact lens wear II. trauma III. infections 1. bacteria such as chlamydia, staphylococcus, pseudomonas 2. viruses such as herpes simplex and herpes zoster 3. protozoa: onchocerca volvulus, leishmania brasiliensis IV. alkali burns V. immunologic diseases 1. Steven-Johnson's syndrome 2. graft rejection 3. cicatricial ocular pemphigoid VI. degenerative disorders 1. pterygium 2. Terrien's marginal degeneration

Ghost vessels
I. Bacterial disease 1. congenital syphilis 2. tuberculosis 3. leprosy II. Viral disease 1. herpes simple 2. herpes zoster 3. measles 4. mumps 5. rubella III. Parasitic disease 1. leishmaniasis 2. onchocerciasis 3. cysticerosis IV. Unknown aetiology V. Cogan's syndrome

Pigments on the endothelium

1. 2. 3. 4. pigment dispersion syndrome pseudoexfoliation syndrome post-cataract surgery previous corneal performation in which the iris was incarcerated in the wound leaving behing pigment 5. trauma 6. idiopathic

50

Differential diagnosis

Breaks in Descemet's membrane

1. congenital glaucoma 2. advanced keratoconus 3. trauma (for example forcep delivery

Mutton fat Keratic precipitates in the endothelium

I. Infectious 1. tuberculosis 2. syphilis 3. Lyme disease 4. toxoplasmosis 5. propiobacterium acnes II. inflammation 1. sarcoidosis 2. sympathetic ophthalmia 3. phacoanaphylactic uveitis 4. Vogt-Koyanagi-Harada's syndrome

Symblepharon
I. Congenital 1. isolated 2. associated with systemic: Goldenharg's syndrome II. Acquired 1. traumatic including chemical injury 2. post-surgical a. pterygium operation b. conjunctival incision for RD or squint surgery 3. inflammatory conditions a. ocular cicatricial pemphigoid b. Steven-Johnson's syndrome

51

Differential diagnosis

Iris transillumination
I. Diffused 1. Fuch's heterochromic cyclitis 2. albinism 3. post-cataract surgery 4. diabetic mellitus 5. previous acute glaucoma causing iris ischaemia II. Sectorial 1. herpes zoster 2. iridoschisis 3. post-cataract surgery 4. previous acute glaucoma 5. iridocorneal-endothelial syndrome III. Peripupillary :pseudoexfoliation syndrome IV. Mid-periphery :pigment dispersion syndrome V. Localized 1. post-trabeculectomy 2. post-laser iridotomy (both iridectomy and iridotomy are usually
found superiorly) 3. post-vitrectomy with silicone implant (Ando's procedure and the iridectomy is performed inferiorly)

Pigmented iris lesion

(the lesion may be solitary or multiple, = differential diagnosis of iris naevus)

1. iris naevus 2. iris melanoma (both melanoma and naevus can cause corectopia ) 3. iris leiomyoma 4. tumour extended from the ciliary body 5. metastatic tumour 6. juvenile xanthogranuloma (in young children) 7. iris cyst (may result from surgery) 8. granuloma (typically in sarcoidosis, termed Koeppe nodules if at the
pupil margin and Busacca nodules if at the periphery) 9. Lisch nodules (usually multiple) 10. Brushfield's spots (seen in Down's syndrome and usually multiple) Corectopia (= diplacement of the pupils) 1. congenital (including coloboma)

2. iris naevus / iris melanoma 3. ectopia uvae 4. ciliary body tumours 5. anterior chamber cleavage syndrome (Axenfeld and Reiger's) 6. iridocorneal-endothelial syndrome 7. post-cataract surgery (+ vitreous loss or the haptic is displaced) 8. post-trabeculectomy

52

Differential diagnosis

Isolated pigmented lesion

1. 2. 3. 4. choroidal naevus choroidal melanoma retinal pigment epithelium hamartoma congenital retinal pigment epithelium hypertrophy

Isolated pale lesion

1. 2. 3. 4. 5. 6. 7. congenital retinal pigment epithelium atrophy amelanotic naevus amelanotic melanoma coloboma of the retina and choroid choroidal metastatic tumour retinal astrocytoma retinoblastoma

Diffuse pigmented lesion

1. multiple congenital hypertrophy of the retinal pigment epithelium 2. rubella retinopathy 3. congenital syphilis 4. watermark in retinal detachment 5. retinitis pigmentosa 6. age-related peripheral retinal pigmentary changes 7. female carriers of choroideremia

Diffused white fundus

I. congenital 1. extensive retinal nerve fiber myelination 2. coloboma of the retina and choroid II. hereditary disorders 1. albinism 2. gyrate atrophy 3. choroideremia 4. diffuse choroidal atrophy III. high myopia IV. vascular: acute retinal ischaemia V. trauma: commotio retinae

Retinal detachments
I. rhegamatogenous II. tractional 1. proliferative retinopathies

53

Differential diagnosis

III.

2. penetrating ocular trauma 3. severe intraocular inflammation exudative 1. choroidal tumours a. melanoma b. other primary tumour c. metastatic tumour 2. intraocular inflammation a. Vogt-Koyanagi-Harada's disease b. posterior scleritis 3. leaking subretinal vessels a. choroidal neovascularisation b. retinal telangiectasia 4. systemic condition a. toxaemia of pregnancy b. malignant hypertension c. hypoproteinaemic states such as nephrotic syndrome 5. others a. retinal photocoagulation b. uveal effusion syndrome

Choroidal detachments
I. ocular hypotony 1. wound leak 2. glaucoma filter 3. cyclodialysis cleft 4. penetrating ocular trauma II. elevated veal venous pressure 1. arteriovenous fistula 2. Sturge-Weber syndrome 3. vortex vein compression by scleral buckle III. malignant hypertension IV. inflammatory factors 1. after photocoagulation or cryotherapy 2. scleritis 3. uveitis V. neoplastic conditions 1. metastatic carcinoma 2. malignant melanoma 3. lymphoid, leukemic or melanocytic choroidal infiltration VI. secondary to abnormal sclera 1. nanophthalmos 2. idiopathic uveal effusion syndrome

54

Differential diagnosis

Relative afferent pupillary defect

I. Retina lesions (extensive resulting in loss of large number of ganglion cells) 1. vascular causes (central retinal artery or vein occlusion) 2. advanced glaucoma 3. infective (toxoplasmosis, CMV retinitis, ARN) 4. total retinal detachment II. Optic nerve lesions 1. optic neuritis 2. AION (non-arteritic or arteritic due to giant cell arteritis) 3. tumours (1ry: glioma and meningioma or 2ry) 4. trauma (traumatic optic neuropathy or optic nerve avulsion) 5. congenital (unilateral optic nerve hypoplasia) III. Chiasmal lesions (if there is more damage to one ON than the other) 1. tumours (1ry: pituitary tumours, craniopharyngioma or 2ry) 2. vascular lesions (internal carotid artery aneurysm) 3. inflammatory (granuloma: sarcoidosis and TB or idiopathic: IV.
Tolosa-Hunt syndrome) Optic tract lesions (if more VFD in one eye than the other)

1. vascular lesions (ischaemic or haemorrhagic stroke) 2. tumours (1ry: meningioma and astrocytoma or 2ry)

Anisocoria
Abnormal small pupil congenital (essential) Horner's syndrome drug-induced Abnormal large pupil congenital (essential) Adie's pupil drug-induced (anticholinergic
blockage or adrenergic stimulation)

(parasympathomimetic)

previous uveitis PS traumatic miosis Light-near dissociation

third nerve palsy damage to the iris (traumatic or infl.)

I. Lesions of the afferent pathway 1. retina (when both eyes are blind as DR absent light response) 2. optic nerves (if both ON are damaged as in GCA) 3. midbrain (pretectal lesion: Parinaud's syndrome due to pinealoma) 4. Edinger-Westphal nucleus (Argyll-Robertson's pupil) II. Lesions of the efferent pathway (caused by aberrant regeneration of the
damaged nerve resulting in better near reaction)

1. third nerve 2. ciliary ganglion (Adie's pupil) 3. other peripheral neuropathies (Charcot-Marie-Tooth syndrome,
amyloidosis, alcoholism and diabetes can also cause light-near dissociation and are probably due to regeneration of damaged nerves) 4. Other cause of unknown aetiology

55

Differential diagnosis

5. myotonic dystrophy

56

Differential diagnosis

Non-pigmented lesion of the lid

I. Epithelial 1. tumours a. benign: keratoacanthoma, actinic keratosis and squamous papilloma b. malignant: BCC, SCC 2. infection as in molluscum contagiosum II. Subepithelial 1. cystic a. epidermoid cyst b. dermoid cyst c. hidrocystoma 2. solid a. chalazion b. syringoma c. sebaceous carcinoma d. xanthelasma 3. vascular a. cavernous haemangioma b. capillary haemangioma

Pigmented lesion of the lid

I. From childhood 1. elevated (melanotic naevus) 2. flat lesion (naevus of Ota, blue naevus) II. First appearance in adulthood 1. elevated a. malignant melanoma b. pigmented basal cell carcinoma c. seborrheic keratosis 2. flat a. lentigo maligna (Hutchinson's freckle) b. lentigo senilis