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13th December 2023
Medication history
- Digoxin is associated with yellowing of vision.
- Phosphodiesterase type-5 (PDE-5) inhibitors (sildenafil, tadalafil, vardenafil) may cause transient blue tints.
- The use of PDE-5 inhibitors has been associated with an increased risk of non-arteritic anterior ischaemic optic neuropathy.
- Amiodarone may cause progressive optic neuropathy.
- Tetracyclines and vitamin A derivatives are associated with raised intracranial pressure.
| Visual acuity | Baseline visual acuity should be documented in all cases, preferably with and without pinhole
Improvement with pinhole suggests a refractive error or ocular media opacity (corneal/lenticular) |
| Visual fields to confrontation | This may detect a hemianopia unnoticed by the patient |
| Pupillary Examination | Fixed and semi-dilated (angle closure glaucoma)
Small, irregular and sluggish (anterior uveitis) |
| Relative afferent pupillary defect | Optic neuropathy even in the presence of a normal-appearing optic nerve head |
| Extraocular eye movements | Painful eye movements (optic neuritis)
Gaze evoked visual loss (orbital lesion) 6TH nerve palsy (raised intracranial pressure) |
| Eyelids | Swollen (orbital cellulitis)
Retraction (thyroid eye disease) |
| Proptosis | Thyroid eye disease
Orbital cellulitis Carotid-cavernous fistula Orbital tumour |
| Conjunctiva/sclera | Redness and injection (orbital or anterior segment disease) |
| Intra-ocular pressure | Significantly raised in acute angle closure glaucoma (>50mmHg) |
| Fundoscopy | Cherry red spot, cotton wool spots, haemorrhages, venous dilation (Retinal vascular occlusion)
Dot/blot haemorrhages (diabetic; hypertensive retinopathy) Macula exudates (diabetic; hypertensive retinopathy) Drusen and macula haemorrhages (age-related macular degeneration) Optic nerve swelling: unilateral vs bilateral (papilloedema) |
| General Examination | Temporal arteries: tenderness, nodules, loss of pulsation
Cardiovascular: atrial fibrillation; heart murmur Neurological: hemiparesis BMI: Consider idiopathic intracranial hypertension in overweight females of child-bearing age Temperature: if elevated, consider orbital cellulitis or infective emboli Blood pressure: uncontrolled hypertension Glucose: undiagnosed diabetes mellitus Urine dipstick for proteinuria if pregnant (pre-eclampsia) |
Source: Denniston, A., & Murray, P. (2018). Oxford Handbook of Ophthalmology (4th ed.) Oxford University Press
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