Strabismus occurs when there is a true disparity of the eye axes, presenting as one or both eyes turning or fixed in a position counter to the patient’s gaze. An inward turning of the eye is termed esotropia, and an outward turn is an exotropia. Additional clinical findings are an asymmetric corneal light reflex along with presentation and notable findings during a cover test and during examination of the six cardinal positions of gaze.
A patient with exophthalmos has a forward displacement or “protrusion” of the eyeball with widened palpebral fissures. Also, the upper eyelid elevates above the eyeball with a prominence of the white sclera visible on inspection. Often, acquired bilateral exophthalmos is associated with an underlying thyroid disorder, such as thyrotoxicosis or Graves Disease.
Ptosis occurs due to neuromuscular weakness of CNIII: the oculomotor cranial nerve, sympathetic nerve damage, or from a congenital defect. It presents as a “drooping upper eyelid,” possibly impairing vision.
Often associated with the loosening of connective tissue and weakening of associated musculature around the eye in advanced age, ectropion is a presenting loose, lagging lower eyelid with exposed palpebral conjunctiva. The eyelid appears to evert away from the eyeball, and the exposed conjunctiva is at risk for inflammation or trauma. The patient often will report irritation, excessive tearing, or symptoms of keratoconjunctivitis sicca (“dry eye syndrome”).
Entropion is common in older adults and occurs when the lower eyelid inverts (“rolls into”) the eye as a result of increased tissue laxity, weakening of periocular eyelid musculature and/or a result of scar tissue contraction. Friction from the inverted eyelashes irritates the cornea, causes a “foreign body” sensation for the patient, and could result in corneal damage if not addressed.
An inflammation of the eyelids, blepharitis presents as thickened, crusted lid margins with a production of red, scaly, and greasy flakes. Common causes are a staphylococcal infection or seborrheic dermatitis, and the patient’s symptoms may include irritation, pruritus of the eye and region, a foreign body sensation, lacrimation and/or pain.
Dacryocystitis is inflammation of the lacrimal sinus sac, resulting in blockage of the nasolacrimal duct and localized infection. Symptoms include pain, erythema, and redness below the inner canthus of the medial eye, toward the nose.
A hordeolum (stye) can appear similar, but is attributed to a staphylococcal infection of the hair follicles causing irritation, redness, and swelling. An infected hordeolum can transmit to the contralateral eye via the hands and can produce a pustule at the hair follicles’ base.
A chalazion presents as a nodule on the eyelid with underlying inflammation to the meibomian glands. It is typically painless, non-infectious (though can lead to), can obscure vision, and presents deep in the pocket of the eyelid near the palpebral conjunctiva.
Anisocoria, or unequal pupil size, exists in about 5% of the general population in its benign presentation, though can also be attributed to central nervous system disease.
Dilated and fixed pupils associated with sympathetic nervous system stimulation. The underlying etiology can be the use of sympathomimetic drug use, use of dilatory eye drops, acute glaucoma, circulatory arrest, trauma, or damage to the CNS.
Miosis is constricted and fixed pupils. These constricted pupils could arise from the use of pilocarpine eye drops (for glaucoma management), narcotic use and/or brain damage at the level of the pons.
Pterygium, as known as Surfer's Eye, is a membranous, triangular, opaque wing covering the bulbar conjunctiva with possible overgrowth over the cornea. It occurs from chronic exposure to hot, sandy, and dry climates stimulating the growth of a pinguecula (smaller, benign growth) into a pterygium. It typically invades the medial canthus and could obstruct vision with the progression of the illness.
Hyphema is blood captured in the anterior chamber from trauma, herpes zoster infection or spontaneous hemorrhage. It can be an emergency if there is suspicion for scleral rupture or major intraocular trauma. Often, blood can pool in the front of the iris and may be asymptomatic.
Hypopyon is the result of white blood cells captured in the anterior chamber and is associated with infections like iritis and/or inflammation of the anterior chamber. Symptoms include pain, irritation, conjunctivitis, and possible vision changes.
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