This contains Protocol for differential diagnosis of common ocular diseases. useful for all eyecare practitioners for diagnosing Ocular conditions correctly and easily.

1. Optom. SIMI AFROZ
A.I.I.M.S, New Delhi
Optom Student’s Power
Protocol for
DIFFERENTIAL DIAGNOSIS
common OCULAR diseases
1

2. Definition
● Differential: A difference between two values
on a scale.
● Diagnosis: Identification of the nature and
cause of problem.
● Differential diagnosis (Ddx)
The process of differentiating between two or
more conditions which share similar signs or
symptoms.
★ Develope a systematic,routine method for
differential diagnosis generation.
2

3. Rules: what is a Ddx?
❖ Recognize a collection of signs and
symptoms.
❖ Recall basic pathophysiology.
❖ Restate in terms of disease.
❖ Reconnect with the initial complaints.
❖ Framing the probability test.
3

4. Sagacious Diagnostic Errors
4
Errors
● faulty hypothesis
generation.
● faulty context formulation.
● Faulty information
gathering.
○ inaccurate
assessment
○ wrong interpretation of
tests
● premature closure of
diagnosis
● “No fault” errors
4
Examples
● Hmm...DOV for near -
presbyopia?
● “35 years old? I thought
you said 45 years old.”
● “ its just u need
refraction.”
● “oh! you are myopic…”
● “This is (+) so you are
having …..”
● “This is(-) so it is not that…”
● “ I am always correct….”

5. Many diagnostic error occur because we try to
fit our hypothesis rather than finding the actual
disease.
5

6. 6

7. Step one: History taking
A careful meticulous approach to history taking is the
foundation of successful clinical diagnosis. Begins by
asking:
● Demographic data: name age, sex, occupation,etc.
● Chief complaints: always be recorded in a
chronological order with their duration.
● History of present illness: make notes of following
points - mode of onset with duration, severity,
progression, accompaniment of each symptom.
● History of past illness: similar ocular complaints in past,
similar complains in other eye, trauma to eye in past,
any ocular surgery in past, any systemic disease in
past, drug intake.
● Family history: in heratable ocular disorders.
7

8. Step two : ocular examination
◻ testing of visual acuity: monocular and binocular
measurement of distance and near visual acuity and if
subject is having glasses then with glasses also.
◻ external ocular examination:
⬜ inspection in diffuse light: preliminary examination of
eyeballs.
⬜ Focal illumination examination: detailed
examination under magnification.
◻ Fundus examination:
⬜ media
⬜ optic disc; shape, size, margins,colour, cup - disc
ratio,neovascularization,etc
⬜ macula
⬜ retinal blood vessels
8

9. Step three: Reconnection
summarize your finding accordingly.
9

10. Step four : Special Tests
Extra test for confirming your diagnosis (if
required).
10

11. Step five: Diagnosis
combine your clinical finding and make final
diagnosis
11

12. Common ocular symptoms and
their causes
Sudden painless loss of vision
◻ Central retinal artery occlusion
◻ Massive vitreous hemorrhage
◻ Retinal detachment including macula
◻ Ischemic retinal vein occlusion
Sudden painless defective vision
◻ Central serous retinopathy
◻ Optic neuritis
◻ Methyl alcohol amblyopia
◻ Non ischemic central vein occlusion
Sudden painful loss of vision
◻ Acute congestive glaucoma
◻ Acute iridocyclitis
◻ Chemical or mechanical injury to eyeball
12

13. Cont...
Gradual painless loss of vision
◻ Refractive error
◻ Pterygium
◻ Corneal degeneration
◻ Corneal dystrophy
◻ Cataract
◻ Optic atrophy
◻ Diabetic retinopathy
◻ Chorioretinal degeneration
◻ Age related macular degeneration
Gradual painful loss of vision
◻ Chronic glaucoma
◻ Chronic iridociclitis
◻ Corneal ulcer
13

14. Cont...
Amaurosis faux
◻ Papilloedema
◻ Giant cell arteritis
◻ Migraine
◻ Hypertension
◻ Carotid artery disease
Night blindness
◻ Vitamin A deficiency
◻ Retinitis pigmentosa
◻ Pathological myopia
◻ Advanced case of POAG
Day blindness
◻ Polar, subcapsular cataract
◻ Central corneal opacity
◻ Congenital deficiency of cone
14

15. Cont...
Defective vision for near
◻ Presbyopia
◻ Cycloplegia
◻ Insufficiency of accommodation
Black spot in front of eye
◻ Vitreous hemorrhage
◻ Vitreous degeneration
◻ Lenticular opacity
Flashes of light in front of eye
◻ Prodromal symptom of retinal detachment
◻ Vitreous traction
◻ Retinitis
Micropsia ,macropsia and metamorphopsia
◻ Central chorioretinitis
15

16. Cont...
Coloured haloes
◻ Acute congestive glaucoma
◻ Early cataract
◻ Mucopurulent conjunctivitis
Diplopia
◻ Uniocular: subluxated lens, double pupil, keratoconus
◻ Binocular: paralytic squint, diabetes, myasthenia
gravis, blow out fracture, anisometropia, after squint
correction in case of ARC.
16

17. Common ocular signs and their
causes
Conjunctiva
Conjunctival follicle
◻ Trachoma
◻ Acute follicular conjunctivitis
◻ Chronic follicular conjunctivitis
Conjunctival papillae
◻ Trachoma
◻ Spring catarrh
◻ Allergic conjunctivitis
◻ Giant papillary conjunctivitis
Concretions
◻ Trauma
◻ Degenerative conditions
◻ Idiopathic
17

18. Cont...
Cornea
Decreased corneal sensation
◻ Herpes simplex keratitis
◻ Neuroparalytic keratitis
◻ Leprosy
◻ Absolute glaucoma
◻ Herpes zoster keratitis
Superficial corneal vascularization
◻ Trachoma
◻ Superficial corneal ulcer
◻ Phlyctenular keratoconjunctivitis
Deep corneal vascularisation
◻ Deep corneal ulcer
◻ Chemical burns
◻ After keratoplasty
18

19. Cont...
Increased corneal thickness
◻ Corneal edema
Abnormal corneal surface
◻ Keratoconus
◻ Corneal ulcer
◻ Corneal aberrations
Anterior Chamber
Shallow anterior chamber
◻ PACG
◻ Hypermetropia
◻ Leaking wound
◻ Corneal perforation
◻ Iris bombe formation
◻ Adherent leucoma
19

20. Cont...
Deep anterior chamber
◻ Aphakia
◻ Myopia
◻ Total posterior synechiae
◻ Keratoconus
◻ Keratoglobus
◻ Anterior dislocation of lens
◻ Posterior perforation of globe
◻ Buphthalmos
Hyphema
◻ Corneal injury
◻ Herpes zoster iritis
◻ Intraocular tumors
20

21. Cont...
Hypopyon
◻ Corneal ulcer
◻ Retinoblastoma (pseudohypopyon)
◻ Endophthalmitis
◻ Panophthalmitis
◻ Iridocyclits
Iris
Nodules on iris
◻ Granulomatous uveitis ( koppe’s and busacca nodules)
◻ Melanoma or oris
◻ Tuberculoma
Neovascularization of iris
◻ Diabetes
◻ CRVO
◻ Sickle-cell retinopathy
21

22. Cont...
Iridodonesis
◻ Dislocation of lens
◻ Aphakia
◻ Hypermature shrunken cataract
◻ Buphthalmos
Pupil
Miosis
◻ Drug induced (Topical)
◻ Effect of systemic morphine
◻ Iridocyclitis( non-reacting irregular)
◻ Horner’s syndrome
◻ Head injury
◻ During sleep
◻ Hyperpyrexia
◻ Poisoning( alcohol, barbiturates, morphine, carboxylic acid)
22

23. Cont...
Mydriasis
◻ Drug induce (Topical)
◻ Acute congestive glaucoma
◻ Absolute glaucoma
◻ Optic atrophy
◻ RD
◻ Internal ophthalmoplegia
◻ Third nerve paralysis
◻ Coma
◻ Severe anaemia
◻ Adie’s tonic pupil
◻ Belladonna poisoning
Leukocoria
◻ Congenital cataract
◻ RB
◻ PHPV
23

24. Cont...
Marcus gunn pupil
◻ Optic neuritis
◻ Optic atrophy
◻ R D
◻ CRAO
◻ Ischemic CRVO
Lens
Subluxation of lens
◻ Trauma
◻ Marfan's syndrome
◻ Homocystinuria
◻ Weil-marchesani syndrome
24

25. Cont...
Retina
Cherry red spot
◻ CRAO
◻ Taysach’s disease
◻ Sialidosis
◻ Metachromatic leukodystrophy
◻ Multiple sulphate deficiency
Macular edema
◻ Trauma
◻ Intraocular operations
◻ Uveitis
◻ Diabetic maculopathy
Superficial retinal hemorrhage
◻ DR
◻ HR
◻ CRVO
25

26. Cont...
Soft exudates
◻ H R
◻ D R
◻ Anemic retinopathy
◻ Retinopathy of AIDS
◻ Eale’s disease
Hard exudates
◻ D R
◻ H R
◻ Coat’s diseases
◻ Old CRVO
Subretinal retinal neovascularization
◻ Wet ARMD
◻ High myopia
◻ Choroidal rupture
◻ Optic disc drusan
26

27. Cont...
Visual field defects
Enlargement of blind spot
◻ Papilloedema
◻ POAG
◻ Drusen of optic nerve
◻ Progressive myopia
Peripheral field contraction
◻ Papilloedema
◻ Papillitis
◻ Optic atrophy
◻ Glaucoma
◻ RP
◻ Quinine and salicylate poisoning
Tubular vision
◻ Advanced glaucoma
◻ RP
27

28. Cont...
Ring scotoma
◻ Glaucoma
◻ RP
Central scotoma
◻ Optic neuritis
◻ Macular hole ,cyst,etc
◻ Tobacco amblyopia
Bitemporal hemianopia
◻ Lesion of mid-optic chiasma
◻ Pituitary Adenomas
◻ Glioma of third ventricle
◻ Craniopharyngioma
◻ Aneurysm of Anterior communicating artery
28

29. Homonymous hemianopia
◻ Optic tract lesion
◻ Lateral geniculate body lesion
◻ Visual cortex lesion (M. sparing)
Binasal hemianopia
◻ Lateral chiasmal lesions
◻ Distension of third ventricle
29
Cont...

30. examples of case
study
30

31. Case - 1
A 32 yr old female (homemaker) come with the complains of
DOV for near especially while stitching with good general
health.
ON examination:
Visual acuity at distance without correction
OD 20/20 OS 20/20
• Visual acuity at near without correction
OD 20/80 OS 20/80
• Entrance tests (color vision, cover test, Randot 2, NPC, EOMs, pupils,
screening visual fields) normal
• Retinoscopy with cycloplegia (H.A. 2%)
OD +1.50 OS +1.50
• Distance subjective refraction
OD +1.00 20/20 OS +1.00 20/20
31

32. Cont..
• Visual acuity at near with distance correction
OD 20/20 OS 20/20
➢ Here two diagnosis come in mind presbyopia and latent
hyperopia. review your examination (age and cycloplegic
refraction)
Finally DDX is LATENT HYPEROPIA
32

33. case- 2
A 22-year-old female medical student. Following an earlier visit with a
different optometrist, patient returned for a 3-month review with
complaints of increasing eye strain, even while wearing glasses. She also
reported intermittent headaches towards the end of the day and
horizontal diplopia.Upon her initial visit 3 months earlier, patient
symptoms included trouble focussing in the distance, severe eye strain
when reading, intermittent headaches, and twitching RE, with both eyes
feeling irritated and watery. general health was good.
On examination:
No history of any ocular surgery Ocular motility: Full
NPC: 15cm
Cover test: D and N both Exophoria with mod recovery
33

34. Cont...
Refraction: cycloplegic( H.A.2%)
R: +0.25/-0.25 x 178 = 6/6 L: Plano/-0.25 x 25 = 6/6
Additional tests:
Prism cover test D: Orthophoric N: 8PD Exophoria
Stereopsis: 40 sec of arc
AC/A: -2: 4exo -1: 7exo 0: 8exo +1:11 exo (blur)
AC/A ratio calculation: (8-4)/2 = 2:1
Prism fusional range (blur/break/recovery):
Distance: BI 6/10/6 BO 6/10/1 Near: BI 6/20/16 BO 6/20/8
34

35. Cont...
BUT : OD 20 sec OS 22 sec
Differential diagnosis:
● Convergence insufficiency
● Accommodative excess
● Large phoria
● Uncorrected refractive error
● Dry eye
● Supranuclear palsy
● Old strabismus surgery
review your examination with AC/A ratio, cycloplegic refraction, dry
eye tests, history, general health.
Finally DDx is CONVERGENCE INSUFFICIENCY
35

36. Case- 3
A 26-years old woman presents with sore, red eyes and yellowish
discharge. She complained that her eyelashes were stuck together
in the morning. She is a contact lens wearer but says that she
cleans them properly and regularly. Both eyes are equally affected.
She has no history of asthma or allergic conditions.
On examination:
● There is uniform engorgement of conjunctival blood vessels.
● Visual acuity at distance without correction
OD 20/20 OS 20/20
● No photophobia & coloured haloes,
● pupil normal
● Anterior chamber depth normal
● IOP Normal
● NO pain
● Fundus normal
36

37. Cont...
Differential diagnosis
● Viral conjunctivitis
● Allergic conjunctivitis
● Acute anterior uveitis
● Acute angle closure glaucoma
review your examination with general health vision, pain,fundus exam
type of discharge, pupil, anterior chamber depth.
Finally DDx is ALLERGIC CONJUNCTIVITIS.
37

38. 38
Clinical features Allergic
conjunctivitis
Viral
Conjunctivitis
Acute anterior
uveitis
Acute angle
closure
glaucoma
Onset Acute Acute over a few days Sudden
Vision good Fair Fair Poor
Unilateral/ Bilateral Bilateral Unilateral Unilateral Bilateral
Pain Mild discomfort Pain and
discomfort
Moderate in the
eye
Severe pain in eye
Secretion Mucopurulent Watery Watery Watery
Photophobia Absent Present Usually present Usually absent
Coloured halos around
light
Present Absent Usually absent Commonly present
Conjunctival congestion Superficial Superficial Deep ciliary Deep ciliary
Pupil Normal Normal Small and irregular Large and
vertically oval
Depth of anterior chamber Normal Normal Normal Shallow
Intraocular pressure Normal Normal Usually normal but
may b raised
Raised
Systemic symptoms absent adenopathy referred pain occasional
vomiting

39. case- 4
● Complaint of: diplopia
headache
inward deviation in right eye
● Age of onset: 14 years of age
● Duration: 5 days
● Family history:nil
● No known systemic illness
● Probable cause:nil
Previous history :-
● Optical - 1. Glasses- nil 2. Prism- nil 3. Contact lenses- nil
● Occlusion - 1. Converse- nil 2. Inverse- nil
39

40. Cont….
● Operative- nil
● Visual acuity (BCVA)- 6/6 (BE)
● Fundus examination– fovea extorted
● Cover test-distance and near both Right esotropia
● Ocular movement
● AC/A ratio : normal
● Investigations
35 Δ
BO 40Δ
BO
● PBC T(Distance)
40 Δ
BO near 40Δ
BO
40Δ
BO 45Δ
BO
● State of binocular vision – Patient had binocular single vision in
levoversion
40

41. Cont...
● Diplopia Charting (at 1m)
uncrossed diplopia
maximum separation dextroversion
Distal images below to right eye
● Synoptophore
fixing right eye fixing left eye
● General Clinical investigations
Patient was advised to get an x-ray of orbit - Normal
41
can’t fix +33° +10°
can’t fix +30° +10°
can’t fix +32° +11°
+25° +15° +5°
+20° +20° +4°
+22° +16° +5°

42. Hess charting
42

43. differential diagnosis
● Right 6th nerve palsy
● Right esotropia
● Right eso duane's retraction syndrome
review your examination with general health, vision,deviation in 9
cardinal position,fundus exam,ocular movements, PBCT, Diplopia
charting.
Finally DDx is Right 6th nerve palsy
43

44. THANK
YOU