Differential Diagnosis

KEPANITERAAN KLINIK ILMU KESEHATAN MATA PERIODE 29 MEI – 9 JULI 2017
(Date created : June 4th 2017 5:32 PM). Date modified 1st : June 24th 2017 5:33 PM Yuliana 2016-061-086
Differential Diagnosis of Ocular Symptoms (Sumber : Wills, Buku hijau)
1. Burning / sensasi terbakar 10. Astenopia (mata lelah waktu 20. HALLUCINATIONS (FORMED IMAGES)
2. Crossed Eyes in Children membaca) 21. HALOS AROUND LIGHTS
3. Decreased Vision / penurunan 11. EYELIDS DROOPING / mata lelah 22. HEADACHE
penglihatan 12. EYELID SWELLING / mata 23. ITCHY EYES / Mata gatal
4. Distortion Of Vision / distorsi bengkak/edema 24. TEARING / mata berair
(perubahan bentuk atau struktur, 13. EYELID TWITCH / kedutan 25. LIGHT SENSITIVITY (PHOTOPHOBIA)
pemanjangan vs pemendekan, 14. EYELIDS UNABLE TO CLOSE 26. PAIN / nyeri
pembesaran vs pengecilan) (LAGOPHTHALMOS) 27. RED EYE / mata merah
5. Mikropsia 15. EYES “BULGING” (PROPTOSIS) 28. “SPOTS” IN FRONT OF THE EYES
6. DOUBLE VISION (DIPLOPIA) / 16. EYES “JUMPING” (OSCILLOPSIA) 29. NIGHT BLINDNESS / buta ayam / buta
penglihatan ganda 17. FLASHES OF LIGHT / kilatan cahaya senja / buta malam
7. DRY EYES / mata kering 18. FOREIGN BODY SENSATION / 30. BLIND PAINFUL EYE / buta dengan
8. EYELASH LOSS / bulu mata rontok kelilipan sakit mata
9. EYELID CRUSTING 19. GLARE / silau
Belum ketemu : General Problems (Wills)

 Mata kotor/belekan, mengganjal, bayangan melayang ??  Kehamilan
 DD/ sakit yang berhubungan dengan penyakit mata  Lyme Disease
 DD/ sakit yang berhubungan dengan penyakit intracranial  Convergence Insufficiency
 DD/ sakit yang berhubungan dengan perubahan local penyakit non-  Accommodative Spasm
okular  Stevens–Johnson Syndrome (Erythema Multiforme Major)
 Vitamin A Deficiency
 trauma  Albinism
 Wilson Disease
 Subluxed or Dislocated Crystalline Lens
 Hypotony Syndrome
 Phakomatoses
Emergency (Vaughan) [ file emergency ]
*dr. cisca wajib baca*
Ocular Disorders Associated with Systemic Diseases (Vaughan)
1
NO Symptoms More common Less common

1 Burning Blepharitis, meibomitis, dry eye syndrome, conjunctivitis Corneal defects, inflamed pterygium or pinguecula,
(infectious, allergic, mechanical, chemical) episcleritis, superior limbic keratoconjunctivitis, ocular toxicity
(medication, makeup, contact lens solutions), contact lens-
related problems.
2 Crossed Eyes in See 8.4, Esodeviations in Children (eyes turned in),
Children or 8.5, Exodeviations in Children (eyes turned out).
3 Decreased Vision 1. Transient visual loss (vision returns to normal within 24 hours, usually within 1 hour).
Few seconds (usually bilateral): Papilledema Impending central retinal vein occlusion, ischemic optic
DD/ lainnya neuropathy, ocular ischemic syndrome (carotid occlusive
(satu mata) Few minutes: disease [ex : thrombosis A. carotid interna), glaucoma, sudden
 Keracunan/ 1. Amaurosis fugax (transient ischemic attack; change in blood pressure, CNS lesion, optic disc drusen, giant
intoksikasi unilateral) cell arteritis, orbital lesion (vision loss may be associated with
obat 2. vertebrobasilar artery insufficiency (bilateral) eye movement).
 hifema
 ablasio serosa Ten to 60 minutes: Migraine (with or without a subsequent
macula headache).
 luksasi lensa 2. Visual loss lasting >24 hours
 perdarahan — Sudden, painless loss
retrobulbar 1. Retinal artery or vein occlusion Other retinal or CNS disease (e.g., stroke), methanol
 oklusi arteri 2. ischemic optic neuropathy poisoning, ophthalmic artery occlusion (may also have
carotid 3. vitreous hemorrhage / kekeruhan badan kaca extraocular motility deficits and ptosis).
4. retinal detachment
DD/ lainnya 5. optic neuritis (pain with eye movement in > 50% of
(dua mata) cases)
 CVA accident 6. sudden discovery of preexisting unilateral visual loss.
dengan
perdarahan —Gradual, painless loss (over weeks, months, or years).
oksipital 1. Cataract Chronic corneal disease (e.g., corneal dystrophy), optic
 Migrein 2. refractive error neuropathy/atrophy (e.g., CNS tumor).
 Intoksikasi 3. open-angle glaucoma
2
 Hipertensi 4. chronic angle-closure glaucoma

maligna 5. chronic retinal disease [e.g., agerelated macular
 Histeria degeneration (ARMD), diabetic retinopathy].
DD/ lainnya kalo — Painful loss: Acute angle-closure glaucoma, optic neuritis (may have pain with eye movements), uveitis, endophthalmitis,
mata tenang tapi corneal hydrops (keratoconus).
penglihatan turun
mendadak 3. Posttraumatic visual loss
1. Ambylopia Eyelid swelling, corneal irregularity, hyphema, ruptured globe, traumatic cataract, lens dislocation, commotio retinae, retinal
toksik detachment / ablation retina, retinal or vitreous hemorrhage, traumatic optic neuropathy, cranial neuropathies, CNS injury
2. Okulopati (perdarahan okspital).
iskemik 4. nonphysiologic visual loss
3. Buta sentral
bilateral
4. Hysteria dan
malingering
5. Retinopati
serosa sentral
6. Uveitis
posterior/
koroiditis
4 Distortion Of Vision Refractive error [including presbyopia, acquired myopia (e.g., Keratoconus, topical eye drops (e.g., miotics, cycloplegics),
from cataract, diabetes, ciliary spasm, medications, retinal retinal detachment, migraine (transient), hypotony, CNS
detachment surgery), acquired astigmatism (e.g., from abnormality (including papilledema), nonphysiologic.
anterior segment surgery, chalazion, orbital fracture, and
edema)], macular disease [e.g., central serous
chorioretinopathy, macular edema, ARMD, and others
associated with choroidal neovascular membranes (CNVMs)],
corneal irregularity, intoxication (e.g., ethanol, methanol),
pharmacologic (e.g., scopolamine patch).
5 Mikropsia Retinopati serosa sentral, parese akomodasi, hysteria atau malingering
DOUBLE VISION 1. Monocular (diplopia remains when the uninvolved eye is occluded)
6 (DIPLOPIA) “bila terjadi gangguan pembiasan sinar pada mata, maka berkas sinar tidak homogen sampai di macula, sehingga
3
menimbulkan diplopia monocular”
Note : u/ memastikan, pasien diminta menutup mata sehat, lalu ditanya “apakah melihat double?”
Refractive error (contoh : myopia tinggi, astigmat tidak Dislocated natural lens or lens implant, macular disease
teratur/irregular, koreksi astigmatisme tinggi yang tidak (contoh : makulopati), retinal abnormality (ex : retinal
sempurna), incorrect spectacle alignment (sehingga detachment), CNS causes (rare), nonphysiologic.
menyebabkan kita melihat melalui tepi kaca mata), corneal
opacity or irregularity (including corneal or refractive surgery), Others : strabismus, post-operasi, migrein, timor intracranial,
cataract (dini), iris defects (e.g., iridodialisis, iridectomy  histeria
sectoral).
Kornea irregular bisa menyebabkan aberasi optic karena :

etiologi :
 Permukaan kornea yg tidak teratur
 mengkerutnya jaringan parut pada kornea
 pemakaian lensa kontak lama
 tekanan kalazion
Katarak  berkas sinar tidak difokuskan dalam 1 per 1 

diplopia monokular
Lainnya :
 Irregular tear film
 Udara atau benda transparan dalam mata
 Spasme irregular dari badan siliar dan megalokornea
2. Binocular (diplopia eliminated when either eye is occluded)
Diplopia ini akan mempengaruhi pasca bedah pada korespondensi retina anomaly +/- amblyopia
DD lainnya :
Esotropia atau strabismus konvergen (satu mata bergulir ke dalam  bayangan di retina jadi terletak di sebelah nasal
macula  benda seakan terletak di sebelah lateral mata  uncrossed diplopia atau homonimus)
Eksotropia atau strabismus dibergen  crossed diplopia atau heteronimus
Phoria/tropia yang tidak dapat dikompensasi
Gangguan konvergen atau divergen
4
Miopia ocular akibat gangguan tiroid, ophthalmoplegia, myositis okular

Psikogenik
kelelahan
— Typically intermittent:
o Myasthenia gravis
o intermittent decompensation of an existing phoria
— Constant:
o Isolated sixth, third, or fourth nerve palsy  parese atau paralisis otot penggerak mata ekstraokular
 CN III yang mengenai 1 otot kemungkinan terjadi karena lesi nuclear (perdarahan, safilis, multiple
sclerosis) atau miastenia gravis
o orbital disease [e.g., thyroid eye disease; idiopathic orbital inflammation (orbital pseudotumor), tumor,
selulitis, perdarahan, sindroma orbita, perlengketan otot penggerak mata]
o cavernous sinus/superior orbital fissure syndrome
o status-post ocular surgery (e.g., residual anesthesia, displaced muscle, undercorrection or overcorrection after
muscle surgery, restriction from scleral buckle, severe aniseikonia after refractive surgery)
o status-post trauma (e.g., orbital wall fracture with extraocular muscle entrapment, orbital edema, sesudah
kontusio serebri, histeri)
o internuclear ophthalmoplegia; vertebrobasilar artery insufficiency
o other CNS lesions
o spectacle problem
7 DRY EYES See 4.3, Dry-Eye Syndrome
8 EYELASH LOSS  Trauma
(MADAROSIS)  Burn
 thyroid disease  hipertiroid
 Vogt–Koyanagi–Harada syndrome
 eyelid infection or inflammation (ex : blefaritis, Herpes Zoster, infeksi jamur)
 radiation
 chronic skin disease (e.g., alopecia areata)
 cutaneous neoplasm
 trichotillomania
9 EYELID CRUSTING Blepharitis, meibomitis, conjunctivitis Canaliculitis, nasolacrimal duct obstruction, dacryocystitis.
5
Why conjunctivitis?
Karena secret hanya dapat dikeluarkan oleh epitel ber-sel
goblet. Pada mata, sel goblet ada di konjungtiva.
Mengapa jumlah secret akan lebih banyak sewaktu bangun

pagi?
Penutupan kelopak yang lama, yakni saat tidur, akan
membuat suhu mata = suhu tubuh (biasanya suhu mata lebih
rendah akibat penguapan air mata). Suhu merupakan
incubator optimal untuk kuman. Hal tsb mengakibatkan
kuman berkembang biak dengan baik sehingga kuman akan
memberikan peradangan lebih berat pada konjungtiva. Inilah
alas an mengapa jumlah sekret akan bertambah di waktu
bangun pagi.
Bentuk secret yang terlihat kadang sudah membantu

mengarahkan kemungkinan penyebab konjungtivitis
10 Astenopia (mata  Kelainan refraksi yang tidak terkoreksi adekuat
lelah waktu  Presbyopia
membaca)  Anisometropia berat
 Insufisiensi konvergen
 Paresis otot penggerak mata
 Penerangan waktu baca yang tidak baik
EYELIDS DROOPING See 6.1, Ptosis
11
EYELID SWELLING 1. Associated with inflammation (usually erythematous).
12 Hordeolum, blepharitis, conjunctivitis, preseptal or orbital Ectropion, corneal abnormality, urticaria or angioedema,
cellulitis, trauma, contact dermatitis, herpes simplex or zoster blepharochalasis, insect bite, dacryoadenitis, erysipelas,
dermatitis. eyelid or lacrimal gland mass, autoimmunities (e.g., discoid
lupus, dermatomyositis).
2. Noninflammatory:
Chalazion; dermatochalasis; prolapse of orbital fat (retropulsion of the globe increases the prolapse); laxity of the eyelid skin;
cardiac, renal, or thyroid disease; superior vena cava syndrome; eyelid or lacrimal gland mass, foreign body.
6
*blefarokalasis
13 EYELID TWITCH Orbicularis myokymia (related to fatigue (little sleep), excess caffeine, medication, or stress), corneal or conjunctival irritation
(especially from an eyelash, cyst, or conjunctival foreign body), dry eye, blepharospasm (bilateral), hemifacial spasm, albinism
(photosensitivity), serum electrolyte abnormality, tourettes, tic douloureux, anemia (rarely).
14 EYELIDS UNABLE Severe proptosis, severe chemosis, eyelid scarring, eyelid retractor muscle scarring, seventh cranial nerve palsy, status-post
TO CLOSE facial cosmetic or reconstructive surgery.
(LAGOPHTHALMOS)
15 EYES “BULGING” See 7.1, Orbital Disease.
(PROPTOSIS)
16 EYES “JUMPING” Acquired nystagmus, internuclear ophthalmoplegia, myasthenia gravis, vestibular function loss, opsoclonus/ocular fl utter,
(OSCILLOPSIA) superior oblique myokymia, various CNS disorders.
17 FLASHES OF LIGHT Retinal break or detachment, posterior vitreous detachment CNS (particularly occipital lobe) disorders, vestibulobasilar
(PHOTOPSIA) (ablasio posterior badan kaca), migraine, rapid eye artery insufficiency, optic neuropathies, retinitis, entoptic
movements (particularly in darkness), oculodigital phenomena, hallucinations.
DD/ lainnya : stimulation.
 traksi
vitreoretinal
 koroiditis
 trauma mata
 hipotensi atau
kolaps
pembuluh
darah retina
 sinkope
 CVA disorder
18 FOREIGN BODY  Dry-eye syndrome,
SENSATION  Blepharitis
 conjunctivitis,
 trichiasis
 corneal abnormality (e.g., corneal abrasion or foreign body, recurrent erosion, superfi cial punctate keratopathy)
 contact lens-related problem
 episcleritis
7
 pterygium
 pinguecula
19 GLARE  Cataract
 Pseudophakia
 posterior capsular opacity
 corneal irregularity or opacity
 altered pupillary structure or response
 status-post refractive surgery
 posterior vitreous detachment
pharmacologic (e.g.,atropine).
20 HALLUCINATIONS  Posterior vitreous detachments (white lightning streaks of Moore)
(FORMED IMAGES)  retinal detachment
 optic neuropathies
 blind eyes
 bilateral eye patching
 Charles Bonnet syndrome
 Psychosis
 parietotemporal area lesions
 other CNS causes
medications.
21 HALOS AROUND  Cataract
LIGHTS  Pseudophakia
 posterior capsular opacity
 acute angle-closure glaucoma or corneal edema from another cause (e.g., aphakic or pseudophakic bullous
keratopathy, contact lens overwear)
 corneal dystrophies
 status-post refractive surgery
 corneal haziness/opaqueness/blur
 discharge
 pigment dispersion syndrome
 vitreous opacities
 drugs (e.g., digitalis, chloroquine)
8
* edema kornea
22 HEADACHE See 10.26, Headache
23 ITCHY EYES  Conjunctivitis (especially allergic, vernal, and viral)
 Blepharitis
 dry-eye syndrome
 topical drug allergy or contact dermatitis
 giant papillary conjunctivitis, or another contact lens related problem.
TEARING 1. Adults
— Pain present: Corneal abnormality (e.g., abrasion, foreign body or rust ring, recurrent erosion, edema), anterior uveitis,
24 eyelash or eyelid disorder (e.g., trichiasis, entropion), conjunctival foreign body, dacryocystitis, dacryoadenitis, canaliculitis,
trauma.
— Minimal/no pain: Dry-eye syndrome, blepharitis, nasolacrimal duct obstruction, punctal occlusion, lacrimal sac mass,
ectropion, conjunctivitis (especially allergic and toxic), emotional states, crocodile tears (congenital or seventh nerve palsy).
2. Children: Nasolacrimal duct obstruction, congenital glaucoma, corneal or conjunctival foreign body, or other irritative
disorder.
Mata gatal dan berair : DD/ lainnya : skleritis, lagoftalmos, kelainan konjungtiva (radang, alergi, jaringan ikat, kalazion)
LIGHT SENSITIVITY 1. Abnormal eye examination
25 (PHOTOPHOBIA) Corneal abnormality (e.g., abrasion or edema), anterior Conjunctivitis (mild photophobia), posterior uveitis, scleritis,
uveitis. albinism, total color blindness, aniridia, mydriasis of any
etiology (e.g., pharmacologic, traumatic), congenital
glaucoma.
2. Normal eye examination: Migraine, meningitis, retrobulbar optic neuritis, subarachnoid hemorrhage, trigeminal neuralgia,
or a lightly pigmented eye.
Others :
keratitis, katarak, psikogenik, miopi, eksotropia, kekeruhan kornea, campak
26 PAIN 1. Ocular
— Typically mild to moderate: Dry-eye syndrome, blepharitis, infectious conjunctivitis, episcleritis, infl amed pinguecula
or pterygium, foreign body (corneal or conjunctival), corneal disorder (e.g., superfi cial punctate keratopathy), superior
limbic keratoconjunctivitis, ocular medication toxicity, contact lens-related problems, postoperative, ocular ischemic
syndrome, eye strain from uncorrected refractive error.
— Typically moderate to severe: Corneal disorder (e.g., abrasion, erosion, infi ltrate/ ulcer/keratitis, chemical injury,
9
ultraviolet burn), trauma, anterior uveitis, scleritis, endophthalmitis, acute angle-closure glaucoma.
2. Periorbital : Trauma, hordeolum, preseptal cellulitis, dacryocystitis, dermatitis (e.g., contact, chemical, varicella zoster, or
herpes simplex), referred pain (e.g., dental, sinus), tic douloureux.
3. Orbital: Sinusitis, trauma, orbital cellulitis, idiopathic orbital infl ammatory syndrome orbital tumor or mass, optic neuritis,
acute dacryoadenitis, migraine or cluster headache, diabetic cranial nerve palsy.
4. Asthenopia: Uncorrected refractive error, phoria or tropia, convergence insuffi ciency, accommodative spasm,
pharmacologic (miotics).
Tambahan : sakit saat pergerakan bola mata

— Neuritis optic
— Influenza
— Selulitis orbita
— Fraktur orbita yang menjepit otot
— Pasca bedah huling
— Hysteria
— Malingering
27 RED EYE 1. Adnexal causes: Trichiasis, distichiasis, floppy eyelid syndrome, entropion or ectropion, lagophthalmos (incomplete eyelid
closure), blepharitis, meibomitis, acne rosacea, dacryocystitis, canaliculitis.
Kelainan bisa
dimana saja 2. Conjunctival causes: Ophthalmia neonatorum in infants, conjunctivitis (bacterial, viral, chemical, allergic, atopic, vernal,
medication toxicity), subconjunctivalhemorrhage, inflamed pinguecula, superior limbic keratoconjunctivitis, giant papillary
conjunctivitis, conjunctival foreign body, symblepharon and associated etiologies (e.g., ocular cicatricial pemphigoid, Stevens–
Johnson syndrome, toxic epidermal necrolysis), conjunctival neoplasia.
3. Corneal causes: Infectious or inflamatory keratitis, contact lens-related problems (see 4.21, Contact Lens-Related Problems),
corneal foreign body, recurrent corneal erosion, pterygium, neurotrophic keratopathy, medicamentosa, ultraviolet or chemical
burn.
4. Other: Trauma, postoperative, dry-eye syndrome, endophthalmitis, anterior uveitis, episcleritis, scleritis, pharmacologic
(e.g., prostaglandin analogs), angle-closure glaucoma, carotid–cavernous fistula (corkscrew conjunctival vessels), cluster
10
headache.
Penglihatan Normal Penglihatan turun mendadak

(+) sekret = konjungtivitis 1. Keratitis
2. Ulkus-ulkus
(-) sekret : 3. Keratomikosis
 Pterigium 4. Glaucoma akut
 Pseudopterigium 5. Uveitis anterior
 Pinguekula 6. Iridosiklitis
 Hematoma subkonjungtiva 7. Sindrom Vogt Koyanagi-Harada
Episkleritis – skleritis 8. Endoftalmitis
9. Oftalmia simpatika
10. Panoftalmitis
11. Glaucomatocyclitic crisis
28 “SPOTS” IN FRONT 1. Transient: Migraine.
OF THE EYES 2. Permanent or long-standing
Posterior vitreous detachment, intermediate or posterior Microhyphema, hyphema, retinal break or detachment,
caused by : uveitis, vitreous hemorrhage, vitreous condensations/debris. corneal opacity or foreign body.
 retinal
 optic nerve
 CNS
disorder
29 NIGHT BLINDNESS Refractive error (especially undercorrected myopia, myopia Vitamin A deficiency, gyrate atrophy, choroideremia.
progresif), advanced glaucoma or optic atrophy, small pupil
(especially from miotic drops), retinitis pigmentosa,
congenital stationary night blindness, status-post panretinal
photocoagulation drugs (e.g., phenothiazines, chloroquine,
quinine).
30 BUTA DENGAN Edema kornea
SAKIT MATA Uveitis
see more : 13.12 TIO sangat tinggi
wills
11
12
DD of Ocular Sign
ANTERIOR CHAMBER/ANTERIOR CHAMBER ANGLE
No Sign Disease
1 Hyphema  Traumatic, iatrogenic (e.g., intraocular surgery or laser)
 iris neovascularization
 herpes simplex or zoster iridocyclitis
 blood dyscrasia or clotting disorder (e.g., hemophilia), anticoagulation
 Fuchs heterochromic iridocyclitis
 intraocular tumor (e.g., juvenile xanthogranuloma, retinoblastoma, angioma)
2 Hypopyon  Infectious corneal ulcer
 Endophthalmitis
 severe iridocyclitis (e.g., HLA-B27 associated, Behcet disease)
 reaction to an intraocular lens (sterile hypopyon)
 retained lens particle
 device contaminant after cataract surgery (toxic anterior segment syndrome)
 intraocular tumor necrosis (e.g., pseudohypopyon from retinoblastoma)
 retained intraocular foreign body
 tight contact lens
 chronic corneal edema with ruptured bullae
 severe infl ammatory reaction from a recurrent cornealerosion
 drugs (e.g., rifampin).
3 Blood in Schlemm Canal on Gonioscopy  Compression of episcleral vessels by a gonioprism (iatrogenic)
 Sturge–Weber syndrome
 arteriovenous fi stula [e.g., carotid–cavernous sinus fi stula (c-c fistula)]
 superior vena cava obstruction
 hypotony.
CORNEA/CONJUNCTIVAL FINDINGS
1 Conjunctival Swelling (Chemosis)  Allergy
 any ocular or periocular infl ammation
 postoperative
 drugs
13
 venous congestion (e.g., c-c fi stula)

 angioneurotic edema
 myxedema.
2 Conjunctival Dryness (Xerosis)  Vitamin A defi ciency
 postcicatricial conjunctivitis
 Stevens–Johnson syndrome
 ocular cicatricial pemphigoid
 exposure (e.g., lagophthalmos, absent blink reflex, proptosis)
 radiation
 chronic dacryoadenitis
 Sjogren syndrome.
3 Corneal Crystals See 4.14, Crystalline Keratopathy
4 Corneal Edema 1. Congenital:
 Congenital glaucoma
 Congenital hereditary endothelial dystrophy (autosomal recessive form is present at birth,
autosomal dominant form has later onset)
 posterior polymorphous dystrophy (PPMD)
 birth trauma (forceps injury).
2. Acquired:
 Postoperative edema
 aphakic or pseudophakic bullous keratopathy
 Fuchs endothelial dystrophy
 contact lens overwear
 traumatic
 exposure
 chemical injuries
 acute increase in intraocular pressure (e.g. angle-closure glaucoma)
 corneal hydrops (decompensated keratoconus)
 herpes simplex or zoster keratitis
 iritis
 failed corneal graft
14
 iridocorneal endothelial (ICE) syndrome

 PPMD.
5 Dilated Episcleral Vessels  Underlying uveal neoplasm
(Without Ocular Irritation or Pain)  Arteriovenous fistula (e.g., c-c fi stula)
 polycythemia vera
 leukemia
 ophthalmic vein or cavernous sinus thrombosis
 extravascular blockage of ophthalmic/orbital venous outfl ow.
6 Enlarged Corneal Nerves 1. Most Important.
Multiple endocrine neoplasia type IIb (medullary carcinoma of the thyroid gland, pheochromocytoma,
mucosal neuromas; may have marfanoid habitus).
2. Others.
 Acanthamoeba keratitis
 Chronic keratitis
 Keratoconus
 neurofi bromatosis
 Fuchs endothelial dystrophy
 Refsum syndrome
 Trauma
 congenital glaucoma
 failed corneal graft
 leprosy
 ichthyosis
 idiopathic
 normal variant.
7 Follicles on the Conjunctiva See 5.1, Acute Conjunctivitis, and 5.2, Chronic
Conjunctivitis.
8 Membranous Conjunctivitis (Removal of the membrane is difficult and
causes bleeding).
 Streptococci
 Pneumococci
15
 chemical burn
 ligneous conjunctivitis
 Corynebacterium diphtheria
 Adenovirus
 Herpes simplex virus
 ocular vaccinia.
(Compare with “Pseudomembranous Conjunctivitis”)
9 Pseudomembranous Conjunctivitis (Removal of the pseudomembrane is easy without bleeding).
See earlier for causes of membranous conjunctivitis, as well as ocular cicatricial pemphigoid, Stevens–
Johnson syndrome, superior limbic keratoconjunctivitis, gonococci, staphylococci, chlamydia in
newborns, and others.
10 Opacification of the Cornea in Infancy  Congenital glaucoma
 birth trauma (forceps injury)
 congenital hereditary endothelial or stromal dystrophy (bilateral)
 PPMD
 Developmental abnormality of the anterior segment (e.g., Peters anomaly)
 metabolic abnormalities (bilateral; e.g., mucopolysaccharidoses, mucolipidoses)
 interstitial keratitis
 herpes simplex virus
 corneal ulcer
 corneal dermoid
 sclerocornea
11 Pannus (Superfi cial Vascular Invasion  Ocular rosacea
of the Cornea)  tight contact lens or contactlens overwear
 phlyctenule
 chlamydia (trachoma and inclusion conjunctivitis)
 superior limbic keratoconjunctivitis (micropannus only)
 staphylococcal hypersensitivity
 vernal keratoconjunctivitis
 herpes simplex or zoster virus
 chemical burn
 ocular cicatricial pemphigoid
16
 aniridia
 molluscum contagiosum
 leprosy.
12 Papillae on the Conjunctiva See 5.1, Acute Conjunctivitis, and 5.2, Chronic
Conjunctivitis.
13 Pigmentation/Discoloration of the  Racial melanosis (perilimbal)
Conjunctiva  Nevus
 Primary acquired melanosis
 Melanoma
 ocular and oculodermal melanocytosis (congenital, bluegray, not conjunctival but episcleral)
 Addison disease
 Pregnancy
 Radiation
 Jaundice
 resolving subconjunctival hemorrhage
 mascara
 conjunctival or subconjunctival foreign body
 pharmacologic (e.g., chlorpromazine, topical epinephrine).
14 Symblepharon (Fusion of the Palpebral  Ocular cicatricial pemphigoid
Conjunctiva with the Bulbar  Stevens–Johnson syndrome
Conjunctiva)  chemical burn
 trauma
 drugs
 long-standing conjunctival or episcleral infl ammation
 epidemic keratoconjunctivitis
 atopic conjunctivitis
 radiation
 congenital
 iatrogenic (postsurgical).
15 Whorl-Like Opacity in the Corneal  Amiodarone
Epithelium (Verticillata)  Chloroquine
 Fabry disease and carrier state
17
 Phenothiazines
 indomethacin.
EYELID ABNORMALITIES
1 Eyelid Edema See “Eyelid Swelling” in Chapter 1, Differential Diagnosis of Ocular Symptoms.
2 Eyelid Lesion See 6.11, Malignant Tumors of the Eyelid.
3 Ptosis and Pseudoptosis See 6.1, Ptosis.
FUNDUS FINDINGS
1 Bone Spicules (Widespread Pigment See 11.28, Retinitis Pigmentosa and Inherited Chorioretinal Dystrophiesm.
Clumping)
2 Bull’s-Eye Macular Lesion Age-related macular degeneration (ARMD), Stargardt disease or fundus flavimaculatus,
albinism, cone dystrophy, chloroquine or hydroxychloroquine retinopathy, SpielmeyerVogt syndrome,
central areolar choroidal dystrophy. See 11.32, Chloroquine/Hydroxychloroquine
Toxicity.
3 Choroidal Folds Orbital or choroidal tumor, idiopathic orbital inflammatory syndrome, thyroid eye disease, posterior
scleritis, hypotony, retinal detachment, marked hyperopia, scleral laceration, papilledema, postoperative.
4 Choroidal Neovascularization (Gray- More Common.
Green Membrane or Blood Seen Deep ARMD, ocular histoplasmosis syndrome, high myopia, idiopathic polypoidal choroidal vasculopathy,
to the Retina) angioid streaks, choroidal rupture (trauma).
Less Common.
Drusen of the optic nerve head, tumors, retinal scarring after laser photocoagulation, idiopathic.
5 Cotton–Wool Spots See 11.5, Cotton–Wool Spot.
6 Embolus See 10.22, Transient Visual Loss/Amaurosis
Fugax; 11.6, Central Retinal Artery Occlusion;
11.7, Branch Retinal Artery Occlusion; 11.33,
Crystalline Retinopathy.
 Platelet–fibrin (dull gray and elongated): Carotid disease, less common cardiac.
 Cholesterol (sparkling yellow, usually at an arterial bifurcation): Carotid disease.
 Calcium (dull white, typically around or on the disc): Cardiac disease.
 Cardiac myxoma (common in young patients, particularly in the left eye; often occludes the
18
ophthalmic or central retinal artery behind the globe and is not seen).
 Talc and cornstarch (small yellow-white glistening particles in macular arterioles; may produce
peripheral retinal neovascularization): Intravenous (i.v.) drug abuse.
 Lipid or air (cotton–wool spots, not emboli, are often seen): Results from chest trauma (Purtscher
retinopathy) and fracture of long bones.
 Others (tumors, parasites, other foreign bodies).
7 Macular Exudates More Common.
Diabetes, choroidal (subretinal) neovascular membrane, hypertension.
Less Common. Macroaneurysm, Coats disease (children), peripheral retinal capillary hemangioma, retinal
vein occlusion, papilledema, radiation retinopathy.
8 Normal Fundus in the Presence of Retrobulbar optic neuritis, cone degeneration, Stargardt disease or fundus fl avimaculatus, other optic
Decreased Vision neuropathy (e.g., Leber hereditary optic neuropathy, tumor, alcohol or tobacco), rod monochromatism,
amblyopia, nonphysiologic visual loss.
9 Optociliary Shunt Vessels on the Disc Orbital or intracranial tumor (especially meningioma), previous central retinal vein occlusion, chronic
papilledema (e.g., pseudotumor cerebri), chronic open-angle glaucoma, optic nerve glioma.
10 Retinal Neovascularization 1. Posterior pole: Diabetes, after central retinal vein occlusion.
2. Peripheral: Sickle cell retinopathy, after branch retinal vein occlusion, diabetes, sarcoidosis, syphilis,
ocular ischemic syndrome (carotid occlusive disease), pars planitis, Coats disease, retinopathy of
prematurity, embolization from i.v. drug abuse (talc retinopathy), chronic uveitis, others (e.g., leukemia,
anemia, Eales disease, familial exudative vitreoretinopathy).
11 Roth Spots (Retinal Hemorrhages with More Common. Diabetes, leukemia, septic chorioretinitis (e.g., secondary to bacterial endocarditis).
White Centers)
Less Common. Pernicious anemia (and rarely other forms of anemia), sickle cell disease, scurvy, systemic
lupus erythematosus, other connective tissue diseases.
12 Sheathing of Retinal Veins More Common. Syphilis, sarcoidosis, pars planitis, sickle cell disease.
(Periphlebitis)
Less Common. Tuberculosis, multiple sclerosis, Eales disease, viral retinitis (e.g., human immunodeficiency
virus, herpes), Behçet disease, fungal retinitis, bacteremia.
13 Tumor See 11.36, Choroidal Nevus and Malignant Melanoma of the Choroid.
INTRAOCULAR PRESSURE
1 Acute Increase in Intraocular Pressure Acute angle-closure glaucoma, glaucomatocyclitic crisis (Posner–Schlossman syndrome), inflammatory
19
open-angle glaucoma, malignant glaucoma, postoperative (see “Postoperative Problems,” this chapter),
suprachoroidal hemorrhage, hyphema, c-c fi stula, retrobulbar hemorrhage, or other orbital disease.
2 Chronic Increase in Intraocular Pressure See 9.1, Primary Open-Angle Glaucoma.
3 Decreased Intraocular Pressure Ruptured globe, phthisis bulbi, retinal/choroidal detachment, iridocyclitis, severe dehydration,
(Hypotony) cyclodialysis cleft, ocular ischemia, drugs (e.g., glaucoma medications), postoperative (see “Postoperative
Problems,” this chapter), traumatic ciliary body shutdown.
IRIS
1 Iris Heterochromia (Irides of Different 1. Involved iris is lighter than normal: Congenital Horner syndrome, most cases of Fuchs heterochromic
Colors) iridocyclitis, chronic uveitis, juvenile xanthogranuloma, metastatic carcinoma, Waardenburg syndrome.
2. Involved iris is darker than normal: Ocular melanocytosis or oculodermal melanocytosis, hemosiderosis,
siderosis, retained intraocular foreign body, ocular malignant melanoma, diffuse iris nevus,
retinoblastoma, leukemia, lymphoma, ICE syndrome, some cases of Fuchs heterochromic iridocyclitis.
2 Iris Lesion 1. Melanotic (brown): Nevus, melanoma, adenoma, or adenocarcinoma of the iris pigment epithelium.
2. Amelanotic (white, yellow, or orange): Amelanotic melanoma, inflammatory nodule or granuloma (e.g.,
sarcoidosis, tuberculosis, leprosy, other granulomatous disease), neurofibroma, patchy hyperemia of
syphilis, juvenile xanthogranuloma, foreign body, cyst, leiomyoma, seeding from a posterior segment
tumor.
3 Neovascularization of the Iris Diabetic retinopathy, ocular ischemic syndrome, after central or branch retinal vein or artery occlusion,
chronic uveitis, chronic retinal detachment, intraocular tumor (e.g., retinoblastoma, melanoma), other
retinal vascular disease.
LENS (see also 13.1. Acquired Cataract)

1 Dislocated Lens (Ectopia Lentis) See 13.10, Subluxed or Dislocated Crystalline Lens.
2 Iridescent Lens Particles Drugs, hypocalcemia, myotonic dystrophy, hypothyroidism, familial, idiopathic.
3 Lenticonus 1. Anterior (marked convexity of the anterior lens): Alport syndrome (hereditary nephritis).
2. Posterior (marked concavity of the posterior lens surface): Usually idiopathic, may be associated with
persistent fetal vasculature.
NEUROPTHALMIC ABNORMALITIES
1 Afferent Pupillary Defect 1. Severe (2 + to 3 + ): Optic nerve disease (e.g., ischemic optic neuropathy, optic neuritis, tumor,
20
glaucoma); central retinal artery or vein occlusion; less commonly, a lesion of the optic chiasm or tract.
2. Mild (1 + ): Any of the preceding, amblyopia, dense vitreous hemorrhage, advanced macular
degeneration, branch retinal vein or artery occlusion, retinal detachment, or other retinal disease.
2 Anisocoria (Pupils of Different Sizes) See 10.1, Anisocoria.
3 Limitation of Ocular Motility 1. With exophthalmos and resistance to retropulsion: See 7.1, Orbital Disease.
2. Without exophthalmos and resistance to retropulsion: Isolated third, fourth, or sixth cranial nerve palsy;
multiple ocular motor nerve palsies [see 10.10, Cavernous Sinus and Associated Syndromes (Multiple
Ocular Motor Nerve Palsies)], myasthenia gravis, chronic progressive external ophthalmoplegia and
associated syndromes, orbital blow-out fracture with muscle entrapment, ophthalmoplegic migraine,
Duane syndrome, other central nervous system (CNS) disorders.
4 Optic Disc Atrophy More Common.
Glaucoma; after central retinal vein or artery occlusion; previous ischemic optic neuropathy; chronic optic
neuritis; chronic papilledema; compression of the optic nerve, chiasm, or tract by a tumor or aneurysm;
previous traumatic optic neuropathy.
Less Common.
Syphilis, retinal degeneration (e.g., retinitis pigmentosa), toxic or metabolic optic neuropathy, Leber
hereditary optic atrophy, Leber congenital amaurosis, lysosomal storage disease (e.g., Tay–Sachs),
radiation neuropathy, other forms of congenital or hereditary optic atrophy (nystagmus almost always
present in congenital forms).
5 Optic Disc Swelling (Edema) See 10.15, Papilledema.
6 Optociliary Shunt Vessels See “Fundus Findings” in this chapter.
7 Pardoxical Pupillary Reaction (Pupil Congenital stationary night blindness, congenital achromatopsia, optic nerve hypoplasia, Leber congenital
Dilates in Light and Constricts in amaurosis, Best disease, optic neuritis, dominant optic atrophy, albinism, retinitis pigmentosa. Rarely
Darkness) amblyopia.
ORBIT
1 Extraocular Muscle Thickening on More Common.
Imaging Thyroid orbitopathy (often spares tendon), idiopathic orbital inflammatory syndrome.
Less Common. Tumor (e.g., lymphoma, metastasis, or spread of lacrimal gland tumor to muscle), c-c
fistula, superior ophthalmic vein thrombosis, cavernous hemangioma (usually appears in the muscle cone
21
without muscle thickening), rhabdomyosarcoma (children).

2 Lacrimal Gland Lesions See 7.6, Lacrimal Gland Mass/Chronic Dacryoadenitis.
3 Optic Nerve Lesion (Isolated) More Common.
Optic nerve glioma (especially children), optic nerve meningioma (especially adults).
Less Common.
Metastasis, leukemia, idiopathic orbital inflammatory syndrome, sarcoidosis, increased intracranial
pressure with secondary optic nerve swelling.
4 Orbital Lesions/Proptosis See 7.1, Orbital Disease.
PEDIATRIC
1 Leukocoria (White Pupillary Reflex) See 8.1, Leukocoria.
2 Nystagmus In Infancy (See Also 10.21, Congenital nystagmus, albinism, Leber congenital amaurosis, CNS (thalamic) injury, spasmus nutans, optic
Nystagmus) nerve or chiasmal glioma, optic nerve hypoplasia, congenital cataracts, aniridia, congenital corneal
opacities.
POSTOPERATIVE COMPLICATIONS
1 Shallow Anterior Chamber 1. Accompanied by increased intraocular pressure:
Pupillary block glaucoma, suprachoroidal hemorrhage, malignant glaucoma.
2. Accompanied by decreased intraocular pressure:

Wound leak, choroidal detachment, over filtration after glaucoma filtering procedure.
2 Hypotony Wound leak, choroidal detachment, cyclodialysis cleft, retinal detachment, ciliary body shutdown,
pharmacologic aqueous suppression.
REFRACTIVE PROBLEMS
1 Progressive Hyperopia Orbital tumor pressing on the posterior surface of the eye, serous elevation of the retina (e.g., central
serous chorioretinopathy), posterior scleritis, presbyopia, hypoglycemia, cataracts, after radial
keratotomy, or other refractive surgery.
2 Progressive Myopia High (pathologic) myopia, diabetes, cataract, staphyloma and elongation of the globe, corneal ectasia
(keratoconus or after corneal refractive surgery), medications (e.g., miotic drops, sulfa drugs, tetracycline),
childhood (physiologic).
22
VISUAL FIELD ABNORMALITIES

1 Altitudinal Field Defect More Common.
Ischemic optic neuropathy, hemi or branch retinal artery or vein occlusion, optic neuritis.
Less Common.
Glaucoma, optic nerve or chiasmal lesion, optic nerve coloboma.
2 Arcuate Scotoma More Common.
Glaucoma.
Less Common.
Ischemic optic neuropathy (especially nonarteritic), optic disc drusen, high myopia, optic neuritis.
3 Binasal Field Defect More Common.
Glaucoma, bitemporal retinal disease (e.g., retinitis pigmentosa).
Rare.
Bilateral occipital disease, tumor or aneurysm compressing both optic nerves or chiasm, chiasmatic
arachnoiditis, nonphysiologic.
4 Bitemporal Hemianopsia More Common.
Chiasmal lesion (e.g., pituitary adenoma, meningioma, craniopharyngioma, aneurysm, glioma).
Less Common.
Tilted optic discs.
Rare.
Nasal retinitis pigmentosa.
5 Blind Spot Enlargement Papilledema, glaucoma, optic nerve drusen, optic nerve coloboma, myelinated (medullated) nerve fibers
off the disc, drugs, myopic disc with a crescent, multiple evanescent white dot syndrome (MEWDS), acute
idiopathic blind spot enlargement syndrome [(AIBSE) may be on spectrum with MEWDS].
6 Central Scotoma Macular disease; optic neuritis; ischemic optic neuropathy (more typically produces an altitudinal field
defect); optic atrophy (e.g., from tumor compressing the nerve, toxic or metabolic disease); rarely, an
occipital cortex lesion.
7 Constriction of the Peripheral Fields Glaucoma; retinitis pigmentosa, or other peripheral retinal disorders (e.g., gyrateatrophy); chronic
23
Leaving a Small Residual Central Field papilledema; statuspost panretinal photocoagulation or cryotherapy, central retinal artery occlusion with
(Tunnel Vision) cilioretinal artery sparing; bilateral occipital lobe infarction with macular sparing; nonphysiologic visual
loss; carcinoma, melanoma, and autoimmune-associated retinopathy; rarely, medications (e.g.,
phenothiazines); vitamin A deficiency.
8 Homonymous Hemianopsia Optic tract or lateral geniculate body lesion; temporal, parietal, or occipital lobe lesion of the brain (stroke
and tumor more common; aneurysm and trauma less common). Migraine may cause a transient
homonymous hemianopsia.
VITREOUS
1 Vitreous Opacities Asteroid hyalosis; synchysis scintillans; vitreous hemorrhage; infl ammatory cells from vitritis or posterior
uveitis; snowball opacities of pars planitis or sarcoidosis; normal vitreous strands from age-related
vitreous degeneration; tumor cells; foreign body; hyaloid remnants; rarely, amyloidosis or Whipple
disease.
24

Differential Diagnosis

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Differential Diagnosis

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KEPANITERAAN KLINIK ILMU KESEHATAN MATA PERIODE 29 MEI – 9 JULI 2017

Differential Diagnosis of Ocular Symptoms (Sumber : Wills, Buku hijau)

Belum ketemu : General Problems (Wills)

NO Symptoms More common Less common

 Hipertensi 4. chronic angle-closure glaucoma

menimbulkan diplopia monocular”

Kornea irregular bisa menyebabkan aberasi optic karena :

Katarak  berkas sinar tidak difokuskan dalam 1 per 1 

Miopia ocular akibat gangguan tiroid, ophthalmoplegia, myositis okular

Mengapa jumlah secret akan lebih banyak sewaktu bangun

Bentuk secret yang terlihat kadang sudah membantu

Tambahan : sakit saat pergerakan bola mata

Penglihatan Normal Penglihatan turun mendadak

 venous congestion (e.g., c-c fi stula)

 iridocorneal endothelial (ICE) syndrome

LENS (see also 13.1. Acquired Cataract)

without muscle thickening), rhabdomyosarcoma (children).

2. Accompanied by decreased intraocular pressure:

VISUAL FIELD ABNORMALITIES

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