Examination External

1. Swelling of the lids or periorbital tissues may indicate orbital cellulitis but this is rarely bilateral (see p. 147).

Visual Acuity

1. Usually unaffected in all of the above with exception of thyroid eye disease.

2. Minimal reduction common in severe conjunctivitis. Conjunctiva

1. Discharge indicates bacterial conjunctivitis.

2. Pull down lower lid and look at the lower conjunctiva in the gutter between the eye and the inner part of the lower lid - grayish translucent globules (best seen under a slit lamp) are associated with chlamydial infection which should be suspected in the sexually active.

3. Evert upper lid (see p. 32) - a roughened injected undersurface occurs in atopic conjunctivitis.

Sclera

1. Injection over medial and lateral aspect of the sclera may indicate thyroid eye disease particularly if the eyes look prominent.

Cornea

1. Stain with fluorescein and look for an ulcer - diffuse staining may be related to exposure secondary to thyroid disease.

2. Marginal ulcers (see p. 40) are associated with blepharitis (see p. 143) -may present with mild discomfort rather than pain.

Pupils

1. An afferent pupillary defect (see p. 7) may indicate optic nerve compression secondary to thyroid disease.

Fundus

1. Fundal appearance is usually normal although small folds in the retina can occasionally be seen in thyroid disease.

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