DVT : OPHTHALMOLOGY

Dr Ruchi Rai
 A 30 yrs old female presents with complains of blurring of vision while
reading and photophobia in bright light . On examination, there is
anisocoria with a large regular pupil in the left eye. Both direct and
consensual light reflex is absent in the left eye . The left pupil responds
slowly to near with slow redilatation . Right eye shows normal pupillary
response. Fundus is normal in both eyes .The most likely diagnosis is:
The most probable diagnosis?
HOLMES –ADIE PUPIL
HOLMES- ADIE PUPIL
Important Tip
• Anisocoria indicates the abnormality of the efferent pathway. In
afferent lesions the pupils are equal in size .
ARGYLL –ROBERTSON PUPIL
HORNERS SYNDROME
RAPD
• Anisocoria more in dark : Horners
• Anisocoria more in light: Holmes –Adie pupil
• A 50 years old male patient ,presented to the emergency department with
persistent fever, cough, and worsening shortness of breath tested positive for
covid-19 . He had fever of 101.2 F, tachypnea and bilateral expiratory wheeze.
Chest radiography revealed bilateral reticular interstitial opacities consistent with
viral pneumonia . On the third day,he was intubated and transferred to the
intensive care unit due to acute respiratory distress syndrome. On the day of his
discharge ,on the 12th day, he complained of sudden onset of loss of vision in his
right eye. On examination RE : pupil reactions were absent . Rest of the anterior
segment was normal . On fundus examination: retinal whitening with cherry –red
spot . Optic nerve has slightly indistinct margin. The most probable diagnosis:
CRAO
CRAO
CILIORETINAL ARTERY
 A middle-aged women presented with the complains of painless dimunition of
central vision in her left eye detected on routine eye examination. She also
complains of difficulty in reading. On examination, visual acuity in RE: 6/9 and LE:
6/24 . IOP in RE is 12mmHg and LE : 13mmHg . Pupils show a brisk reaction in the
RE whereas the LE shows mild RAPD. There are mild lenticular changes in both
eyes. Visual field examination shows centrocaecal scotoma in the left eye and
superotemporal field loss respecting the vertical meridian in the right eye. Fundus
shows temporal pallor in both the eyes with normal macula and periphery. MRI
brain showed a sellar mass with characteristic “Snowman” appearance The lesion is
in
 A 35 year old man presented with blurry vision in the right eye since
one week . The images in his right eye were distorted .He noticed his
symptoms several days after starting oral steroids for arthritis in his
wrist . There is no history of floaters or photopsia. No history of DM
and HT . On examination ,visual acuity in RE: 6/9 and LE: 6/6 . IOP is
normal in both eyes . BE: Pupils are round and reacting. Slit lamp
examination: BE : Anterior segment is normal.On fundus examination
RE: Ring Reflex at the foveal area .LE: Fundus is normal. Amsler Grid
Test showed central distortion . Field testing showed a relative central
scotoma . The most probable diagnosis
CSR : RING LESION
METAMORPHOPSIA ON AMSLERS GRID
OCT-CSR
INK-BLOT PATTERN – FFA -CSR
SMOKE-STACK PATTERN -CSR
A 45 yrs male patient has presented with gradual blurring and
dimunition of vision in his right eye . On examination visual acuity RE:
6/24 LE: 6/6 . Slit lamp examination shows heterochromia iridis. RE :
cornea : few stellate KPs , AC : mild flare and few cells are seen ,
atrophic patches in the iris . Lens : posterior subcapsular cataract . LE:
Normal . On gonioscopy: RE shows small blood vessels in the angle .LE:
normal findings. IOP : RE : 13mmHg LE: 12 mmHg . The most probable
diagnosis:
FUCH’S HETEROCHROMIC CYCLITIS
AMSLERS SIGN : FUCH’S UVEITIS
 A 60 years female presents to the eye OPD with complains of marked
dimunition of vision in her right eye with severe pain .redness and
watering . She has undergone cataract surgery of the right eye 4 days
back . On examination RE : visual acuity : 6/60 [ in contrast to the
records of her VA of 6/9 in the immediate postop period]. RE: marked
conjunctival congestion, chemosis,corneal haze and hypopyon. Pupils
show RAPD in the RE . Fundus glow is absent. USG B SCAN shows
vitreous exudates . LE : NAD
• The probable diagnosis :
ENDOPHTHALMITIS
USG B SCAN : ENDOPHTHALMITIS
 A 57 years old male presented with complaints of blurring of near
vision. . He has headache, fatigue and progressive weakness in his legs
.. On eye examination, his BCVA was 6/9 in both eyes.Pupils were
equal and reactive with no afferent defects. Slit lamp examination
revealed bilateral nuclear sclerosis. Ocular motility testing revealed
adduction lag in RE with associated abduction nystagmus in the LE.
Convergence is normal .. Visual field testing revealed no central
scotoma or neurological visual field defects .The most probable
diagnosis ?
INO – RT MLF LESION
ONE AND A HALF SYNDROME
• CONVERGENCE FAILURE: This indicates that the lesion involves the
MLF in the midbrain. This is labelled as Anterior INO
• INTACT CONVERGENCE: It indicates that the MLF is involved more
caudally in the PONS ,sparing the medial rectus subnucleus. This is
labelled as Posterior INO
• BINO: THIS IS INO IN EACH EYE WITH BILATERAL ADDUCTION DEFICITS
WITH BILATERAL ABDUCTING NYSTAGMUS
• WEBINO: THIS IS BINO WITH MANIFEST EXOTROPIA IN PRIMARY
POSITION.
• ONE AND HALF SYNDROME: IT’S A GAZE PALSY IN ONE DIRECTION
WITH INO IN THE OPPOSITE DIRECTION
LEFT MLF LESION
 1 yr old child presents in the eye opd with parents complaining of
white pupil of his left eye. The red reflex testing with a direct
ophthalmoscope showed leukocoria in the LE. Left eye showed
esotropia of 15 prism dioptres. Detailed examination under anesthesia
was done . Tonometry: RE: 12mmHg LE : 13mmHg Corneal diameter in
both eyes was normal. Anterior segment is normal. Fundus
examination RE: normal LE: single large tumour at the macular area.
USG scan showed calcification within the tumour . The most probable
diagnosis?
LEFT LEUKOCORIA
RETINOBLASTOMA
USG B SCAN – RETINOBLASTOMA
 A 28years old female patient presents in the opd with dimunition of
vision and glare in both eyes. She is tall , thin statured with
disproportionately long limbs and arachnodactyly. On examination ,
the. Visual acuity is RE : 6/12 and LE : 6/18 . Glasses used by the
patient : RE: -6.25D sph +3 cyl at 135 degree and LE -5.0D sph +2.75 D
cyl at 45 degree . Pupils : No anisocoria and no RAPD . IOP RE: 12
mmHG LE : 14mmHg . Slit lamp examination in oblique illumination
showed an inferior subluxation of lens .Fundus in both eyes is normal..
What is the most probable diagnosis?
SUBLUXATION OF LENS WITH GOLDEN
CRESCENT
 A 40 years male patient presents in the eye OPD with complains of
dimunition of vision ,which is more prominent at night. On examination
: He is using specks of -7 in both eyes with BCVA of 6/12 in his right eye
and 6/18 in his left eye. BE : Anterior segment : Post subcapsular
cataract .On fundus examination: bilateral mid-peripheral bone –
spicule pigmentary changes and RPE atrophy associated with arteriolar
thinning. There is mild disc pallor . ERG showed a reduced scotopic
response.
• What is the most probable diagnosis :
RETINITIS PIGMENTOSA
ERG : RP
 A 55 years male presents with the complains of blurred vision
,discomfort and coloured halos in his left eye. He gives history of a
similar episode 5 years back. On examination of the left eye, his IOP is
53mmHg. In the RE , IOP is 18 mmHg.Slit lamp examination of LE
shows mild corneal edema with single KP and few aqueous cells .
Nuclear sclerotic changes in the lens are present .The iris is
hypochromic with a peripheral iridotomy done . The pupils are dilated
and reacting sluggishly. RE: Anterior segment shows mild nuclear
sclerotic changes in the lens . On gonioscopy ,both eyes: the angles
are open. . Fundoscopy shows C:D ratio of 0.4 in the LE and 0.3 in the
RE. What is the most probable diagnosis?
POSNER SCLOSSMANN SYNDROME
SLIT LAMP FINDING : AQUEOUS CELL
ACUTE CONGESTIVE GLAUCOMA
A 22 year male presents with progressive loss of vision R>L .On examination
VA: RE : 6/36 LE: 6/12 . Anterior segment examination:
• RE: Clear ectatic cornea, with striae and iron deposition on the cornea .
There was v shaped deformity of the lower lid on downgaze. LE: Clear
cornea with mild ectasia
Pachymetry showed : RE: Central thinning [419 microns, thinnest is 360
microns on pachymetry ] LE: central thinning [467 microns, thinnest is 396
microns on pachymetry ]
Corneal topography shows myopia with irregular astigmatism in both eyes .
• Fundus : BE is normal .
KERATOCONUS
VOGTS STRIAE
MUNSONS SIGN
FLEISCHERS RING
 A 31 years old obese female presented to her eye doctor with history
of headaches and transient visual obscurations for the past 6 months .
She also gave history of ringing sensation in the ear for the past 1 year.
On examination: visual acuity RE : 6/6 and LE : 6/9 BE : anterior
segment is normal with normal IOP. Pupils are round and reacting with
no RAPD. Colour vision testing is normal in both eyes. On fundus
examination: bilateral disc edema. MRI brain was normal . Lumbar
puncture showed elevated pressure. The most probable diagnosis.
DISC EDEMA WITH VENOUS DILATATION
 A 59 yrs female patient presents to the eye opd with gradual
dimunition of vision more in her RE. She also complains of increasing
difficulty with glare from bright lights at night,seeing roadsigns and in
reading newspaper. The patient is hypertensive with type 2 diabetes.
On examination RE : VA RE : HM LE: : counting fingers at 3 feet . Pupils
are round and reacting with iop of 21mmHG in her right eye and
20mmHg in her left eye. Anterior segment RE :4+ brunescent nuclear
sclerosis , nucleus appeared sunken inferiorly in the surrounding
cortex. LE: 3+ Nuclear sclerosis and diffuse cortical changes . Fundus
examination was not possible due to opaque media . USG Bscan : BE no
mass lesion or retinal detachment . Diagnosis?
MORGAGNIAN CATARACT
NUCLEAR CATARACT
USG B SCAN : CATARACTOUS LENS
 A 64 year old male noted the onset of oscillopsia 5 months prior to
the presentation. On examination: BCVA in RE: 6/9,LE: 6/6P. The pupils
are round and reacting ,No RAPD . Ocular movement : full movements
with see-saw nystagmus. In one half of the cycle the right eye will rise
and intort and left eye will fall and extort , in the next half of the cycle
this reverses. Visual field charting shows bitemporal hemianopia. On
fundus examination, there is optic nerve pallor in a bow tie
distribution. Where is the lesion?
BITEMPORAL HEMIANOPIA
SEE SAW NYSTAGMUS
BOW- TIE PATTERN OF OPTIC ATROPHY
 A 58 years female patient presents with progressive loss of peripheral vision with
floaters in her right eye. There is no history of flashes of light.On examination
,patient is orthophoric with full coular motility. BE: VA: 6/6 ,IOP : BE 12mmHg ,
visual field examination shows a total superotemporal deficiency in the RE and
normal field in the left eye . Slit lamp examination : RE: anterior chamber is deep
and quite with normal iris , mild lenticular changes, and anterior vitreous cells. LE:
mild lenticular changes are present , rest is NAD . On fundus examination: RE:
Elevated peripapillary ,moderately pigmented collar buttonshaped choroidal mass
with overlying RPE metaplasia inferonasal to the disc. The retina shows grey reflex
in the inferior part ,which is convex and smooth and associated with shifting fluid.
LE: fundus is normal .. The most probable diagnosis?
CHOROIDAL MELANOMA
CHOROIDAL MELANOMA WITH EXUDATIVE
RD
EXUDATIVE RD SHOWING SHIFTING FLUID
 A 39 year old male patient presents with cloudy vision , photophobia and pain in
his right eye since 3 weeks . The pain since then has increased to 8 out of 10 on a
pain scale. He is a contact lens wearer, and at the time of presentation he was on
Gatifloxacin and tobramycin eye drops every hour and cyclopentolate 1% twice a
day in his right eye. Despite the therapy , the ulcer was persisting and was
worsening. On examination: RE: VA is Finger count .LE: 6/6 . Ocular motility was
full. Iop in RE: 19mmHg LE : 18 mmHg . BE: pupils are round and reacting with no
RAPD. Corneal sensation in RE: decreased and LE : normal RE: ring lesion on the
cornea with hypopyon. Few KPs are present alongwith aqueous cell and flare .
Enlarged corneal nerves are appreciated on magnification. LE: normal . Fundus
examination : RE: not possible due to hazy media/ LE: normal, most probable
diagnosis:
ACANTHAMOEBA KERATITIS: RING WITH
HYPOPYON
RING LESION: ACANTHAMOEBA KERATITIS
 A 53 yrs old male patient presents with gradual dimunition of vision L >
R . He has Type 2 diabetes and hypertension. His BCVA in RE is 6/12 and
LE is 6/24 . Slit lamp examination shows: bilateral lenticular changes
{l>R} . On fundus examination: multiple microaneurysms seen in both
eyes in the macular area alonwith few hard exudates . FFA was done
for this patient, which showed multiple hyperfluorescent dots. The
most probable diagnosis?
SNOWFLAKE CATARACT
MILD NPDR
FFA: MICROANEURYSMS
LOOPING OF VEINS: PRE-PROLIFERATIVE
PROLIFERATIVE DR
PRP
 A 25 yrs old lady presents with sudden,severe bilateral loss of vision
with no perception of light. On examination BE : anterior segment is
normal. Pupils are round and reacting with no RAPD . Fundus : BE was
normal. The patient was tested on OK Drum test which showed a
normal response. The most probable diagnosis?
OPTOKINETIC DRUM
OPTOKINETIC NYSTAGMUS
• A 57 years female complains of bilateral central photopsia for two
years. She is currently being treated for Sjogrens syndrome with
methotrexate and prednisolone. She had been previously treated
with Hydroxychloroquine for 10 years [ 6.5mg/kg] , which was
stopped 1 year back. On examination , the visual acuity RE: 6/12 LE:
6/9. Pupils are round and reacting with no RAPD . Ocular movements
are full and visual field shows paracentral scotoma with decreased
foveal sensitivity in both eyes . BE: No verticillata . Mild lenticular
changes on both eyes. Fundus examination: BE: Paracentral
depigmentation of the RPE at the macular area , sparing the fovea.
FFA shows paracentral hyperflourescence .
VORTEX KERATOPATHY
BULLS EYE MACULOPATHY
PARACENTRAL SCOTOMAS : AUTOMATED
PERIMETRY
BULLS EYE MACULOPATHY