Advanced Physical Assessment
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Most common cause of blindness is | age related macular degeneration- cannot do anything about it- ARMD
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| Older adults and vision impairment | refractive errors, cataracts, ARMD, & glaucoma (Leading cause of blindness in AA)
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| How are things perceived on the retina? | is up side down & reversed-nerve impulses are conducted through the retina, optic nerve & optic tract on each side to end in the visual cortex, a part of the occipital lobe
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| The Near Reaction- 3 things- | 1. The pupil constricts shifting gaze from far object to a near one 2. Convergence by the medial rectus & 3. Accommodation of the lenses by ciliary muscles to bring near objects into focus
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| Anything that effects pupil size is | a big deal- effects intracranial nerves- window to the brain- can be a tumor
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| The light reaction | light on one eye- create nerve impulse called transduction- goes ↓ optic nerve-efferent impulses goes to both eyes to constrict both pupils- Direct reaction (eye w/the lt)-Consensual reaction (contralateral eye)
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| The light reaction is lost when | in any condition that damages the optic nerve- optic neuritis-
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| The most accurate way to dx optic neuritis | loss of the light reaction- called afferent pupillary light defect
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| The sensory pathways | retina, optic nerve (CN II), and optic tract, which diverges in the midbrain
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| The motor pathways | impulses back to the constrictor muscles of the iris of each eye are transmitted through the oculomotor nerve CN III
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| For each eye, there is a temporal and nasal field- describe | Photoreceptors in the retina change light to nerve impulses that travel to the visual cortex of the occipital lobe via the optic nerve-
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| Impulses from the nasal side of the retina | cross to the contralateral side to the visual cortex on the opposite side-lesions can =visual defects
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| Impulses from the temporal side of the retina | go to the same-side visual cortex-Lesions= visual field defects- from right temporal retina to right occipital lobe, from left temporal retina….
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| Only fibers that come from the nasal retina | cross to the opposite side
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| Test question- If a pt does not see the temporal fields, only the middle fields | bitemporal hemianopsia- pressing on the optic chiasm- pituitary adenoma
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| Any pituitary tumor, when it grows big enough will press the | optic chiasm- pressing on the nasal fibers
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| 3 nerves that control the 6 muscles of the eye | cranial nerve 3 controls all except 2 LR6 & SO4- lactated ringer 6 and sulfate 4- lateral rectus and superior oblique
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| What do the oblique muscles of the eye do? | the opposite of what they sound- superior oblique moves it down and inward whereas lateral rectus- to the side, inferior rectus is ↓
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| For conjunctiva, the most important question is… | can you see me, can you drive? Alarming
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| Visual acuity is expressed how | inn two numbers (e.g. 20/30)- the first indicates the distance of the pt. from the chart, and the second, the distance at which a normal eye can read this line of letters
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| What if your office is not big enough to hang a Snellen chart 20 ft from the pt? | hang it on a mirror
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| Confrontation testing of the visual fields is valuable for | detection of lesions in the anterior and posterior visual pathways- static finger wiggle test- combining tests- red target test- part of the visual field may be missing
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| Position & Alignment of the Eyes- deviations of the eyes are called | inward is esotropia, outward is exotropia and bulging is exothalmus
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| scaliness of eyebrows occurs | in seborrheic dermatitis
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| Dryness: from impaired tear secretion is seen in | Sjögren syndrome
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| Nasolacrimal duct obstruction testing | press on the duct if it’s not painful- look for puss-
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| Cornea, lens, Iris, and Pupils/ depth of anterior chamber | corneal opacities, cataract, & light reflection, assess the depth of the anterior chamber with light shining directly from the temporal side, look for a crescentic shadow on the medial side of iris- assesses glaucoma d/t ↑pressure
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| conjunctiva and sclera | look at the color
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| what 8 areas do you check during the eye exam? | visual acuity, visual fields, {alignment, eyebrow, eyelids}, lacrimal apparatus, conjunctiva/sclera, cornea/lens/pupils, extraocular movements, and fundus examination
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| what does PERL No RAPD mean? | no relative afferent pupillary defect- ask the pt to stare ahead & w/the lts off check pupils response to lt, do swinging lt test to make sure there’s no RAPD- pt can converge and fix on an object from a distance- optic neuritis detected with swing test
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| afferent vs efferent | brain →pupil is efferent and pupil to brain is afferent
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| Direct reaction | constriction of the same-side (illuminated) pupil
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| What if you shine the light in one eye and it does not constrict and the other eye doesn’t either? | optic neuritits
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| Swinging light test | upon swinging light into one pupil, then into the other, the illuminated pupil constricts & also does the opposite one
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| The relative afferent pupillary defect | direct and consensual reaction are lost when light is shone on the affected side- it’s okay on the normal side but not on the affected side (optic nerve- swing light test)
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| The Near Reaction test | with gaze shift to near objects 3 things happen 1) Pupillary constriction 2) convergence 3) Accommodation
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| 6 cardinal directions for gaze in order | extreme right, right upward, down right, no pausing, extreme left, left ↑ and then left↓
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| Do cranial nerves cross in the eyes? | NO
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| What are some reasons you would not use mydriatic drops? | (1) head injury& coma, (2) suspicion of narrow-angle glaucoma (shallow anterior chamber)
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| Ratio of cup-to-optic disc is | 1/3 or less, if it’s greater it can be chronic open angle glaucoma
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| Red reflex absence | Absence in elderly = cataract. In children, a retinoblastoma may obscure the reflex
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| Swelling of the optic disc and bulging of the physiologic cup, loss of SVPs is | papilledema
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| Arteries and veins crossing | AV nicking, copper wiring in hypertensive changes
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| Retina adjacent to disc | Hemorrhages, exudates, cotton-wool patches, microaneurysms, pigmentation
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| Check macular area of fundus for | Macular degeneration- temporal to the optic disc and ↓ward
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| Anterior structures of the fundus | Vitreous floaters, cataracts
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| Inspect eyelids for swelling, epicanthal folds of neonates | (may be suggestive of Down syndrome)
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| Sunsetting sign in kids | look for sclera above the iris in hydrocephalus- sunken down
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| Hypertelorism in kids | wide spacing between the eyes, associated with craniofacial defects including some intellectual disability
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| Congenital glaucoma: | might manifest as enlarged corneas
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| Coloboma (Keyhole pupil) | failure of fetal tissue to form normally. Usually asymptomatic. Visual acuity may be decreased (needs correction of refraction). Amblyopia may occur.
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| Red reflex | Assess bilaterally in every newborn for opacities, cataract, retinoblastoma
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| Red eye | too much blood in the conjunctiva- (may be infection, Acute angle closure glaucoma, uveitis or iritis)
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| anterior uveitis | (infx of ciliary body/iris), iritis if pupillary constriction causes severe pain- severe cause it’s in the iris
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| danger signals of red eye | burred vision (glaucoma), ↓visual acuity, pain, photophobia, halo, ciliary flush, corneal opacity, abnormality in pupils size, shallow ant chamber (glaucoma), ↑pressure, sudden proptosis (hemorrhage in back)
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| Iritis can be differentiated from conjunctivitis by | determining whether pupillary constriction causes pain in the red eye. Painful pupillary constriction in response to light or accommodation is consistent with iritis
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| What are the fibers in the optic chiasm | nasal fibers- and a pituitary tumor can compress here- so if there’s a disruption here, there are no temporal fields- bitemporal hemianopsia
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| The nasal fiber of the right eye sees what? | the right temporal field and nasal fiber of the left eye sees, the left temporal field- so a disruption at the chiasm disrupts the temporal fields
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| What if there’s a lesion that damages outside the optic chiasm? | ie; calcification in the internal carotid- nasal field is interrupted- binasal-hemianopsia
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| Total blindness left eye | Due to a lesion of the left optic nerve
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| Any lesion behind the optic chiasm, lets say on the right side | will not see on the left side- it’s the opposite Left homonymous hemianopia- left side of both eyes cannot see-Due to lesion of the optic tract
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| Homonymous Left Superior Quadrantic Defect | “pie in the sky” Due to partial lesion of the optic radiation in the temporal lobe- a lesion that’s up effects down and a lower lesion effects what’s up
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| Ptosis | droopy eyelid- myasthenia gravis, horner syndrome, CNIII
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| Lower eyelid inverted | entropion-
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| Lower eyelid turned outward | ectropion
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| Episcleritis | triangular, localized ocular inflammation of the episcleral vessels-movable over the scleral surface- May be nodular- Seen in rheumatoid arthritis, Sjögren syndrome, herpes zoster
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| Blephritis | inflammation of the eyelids- s.aureus- or scaling seborrheic
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| Stye/ hordeolum | infection/staph infection- topical antbx- warm compresses- sebaceous glands- no steroids
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| Chalazion | cyst or gland inside the eyelid- meibomian- not an infx- use warm compress
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| Arcus Senilis (Corneal Arcus) | A thin greyish white arc or circle not quite at the edge of the cornea, accompanies aging- In young adults, suggests possible hyperlipoproteinemia.
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| Kayser-Fleischer Ring | too much copper- slit lamp exam- Wilson syndrome- A golden to red brown ring, sometimes shading to green or blue-present with liver disease, neurologic and psychiatric symptoms
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| Lisch nodules | These are nevi of the iris that are associated with neurofibromatosis-asymptomatic. May be associated with glaucoma
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| Pterygium | A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side-Reddening may occur-may interfere with vision as it encroaches on the pupil
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| Corneal abrasion | Do fluorescein stain/wood lamp exam- Refer Herpes keratitis to ED or ophthalmologist STAT.
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| A cataract | absent red reflex- is an opacification/clouding of the lens- steroids can accelerate
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| Sympathetic fibers __________ the pupils and the parasympathetic fibers _________ the pupils | dilate, constrict
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| If the difference in your pupils is greater in bright light than in dim light and when you dim the difference does not show (eyes dilate) | the larger pupil cannot constrict- in bright light- it should constrict- it’s parasympathetic trauma or open angle glaucoma
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| When the difference in size is more in dim light | it’s sympathetic the smaller pupil cannot dilate horner syndrome
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| Anisocoria is what? | unequal pupils- CN III- It occurs when there is asymmetric disease of the iris
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| Adie vision | pupil constrict to near vision but not to light- unilateral- when it is bilateral it is called Argyll-Robertson pupils
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| Test question- Marcus-Gunn Pupil | optic neuritis- It is a RAPD from optic neuritis- Abnormal dilatation of the pupil of the affected eye when light is shown in it- When light is shown in the normal eye, the pupil of the affected eye will dilate
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| What is disconjucate gaze | cross eye- caused by imbalance of ocular muscle tone, strabismus- examine extraocular movements- intracranial nerve issues (lesions) LR6 SO4 (nasal upshooting) or CR3 esotropia/in, exopropia/out, hypertropia/up- which vranial nerve?
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| SO4 does what? | cranial nerve 4- damage w/trauma- superior oblique -downward- inferior oblique is upward
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| LR6 does what? | eye crossing- cranial nerve 6- gets damaged w/ ↑intracranial tension
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| 3rd cranial nerve supplies what | pupils and eyelid- oculomotor damage- out down droopy dilated
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| Most common causes CN damage | diabetes and HTN
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| The fibers that cause pupillary constriction run where | outer surface of the nerve- diabetes and HTN start inside so the pupils will NOT be effected- looks out and down- pupils okay- anything causing pupil constriction is DANGEROUS- ie; tumor
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| In optic neuritis, the disc margin is | blurred- so when you see it blurry and fuzzy, is it papilledema or optic neuritis--? Swinging lt test
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| Papilledema is | ↑ intracranial pressure
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| Optic neuritis causes | pain with eye movement, acute loss of central vision, and afferent defect in the involved eye (swinging eye- will not constrict with light) – more serious
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| Glaucoma has an | increase cup/disc ratio, ↑ pressure, The diagnostic test is Schiotz tonometry to measure the intraocular pressure- measure the lateral fields
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| Hypertensive retinopathy- 4 grades | from narrowing→AV nicking- interruption of blood flow→ cotton-wool spots, arteriosclerosis, flame-shaped hemorrhages& exudates→ Neuroretinal edema, including papilledema
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| Diabetic retinopathy- non-proliferative- effect on fundus and retina | the earliest retinal changes- background retinopathy→ 1. Microaneurysms 2. hard exudates, 3. blot hemorrhages 4. cotton wool spots, and 5. venous beading- not much can be done
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| Diabetic retinopathy- proliferative-effect on fundus and retina- | see the retina full of new vessels- no light- laser or VEGF inhibitors used- final and most severe stage of diabetic retinal disease. PDR is characterized by 1. neovascularization and 2. fibrous proliferation
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| Macula is what | the center where you see things the clearest
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| Age-Related Macular Degeneration | gradual loss of central vision- wet type-new bv can laser and do VEGF and dry type (most common)- yellow exudate called DRUSEN- cannot do anything for it
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| Retinal detachment | hx trauma-sudden vision loss or floaters, flashing lights- ophthalmologist should be consulted to evaluate any difference in “red reflex” (lighter red reflex) between the two eyes
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| Pterygium | A yellow triangular thickening of the conjunctiva that extends to the cornea on the nasal cornea- redness of eye- foreign body sensation-
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| Allergic conjunctivitis will be accompanied by | allergic rhinitis
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| Acute uveitis | ciliary congestion- red flag- Photophobia, ↓vision in affected eye, Watery discharge, No f/c, no recent illness. No ill contacts, STAT ophthalmology referral for slit-lamp examination and a dilated fundus exam
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| amaurosis fugax | with TIA- loss of vision comes and goes
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| age related eye impairment- 3 things | macular degeneration, glaucoma, cataracts
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| Horner’s syndrome | eyelid ptosis, myosis and anhidrosis- pseudoenophthalmos- sinking of the eyeball into the face- ↓sweating on affected side of the face-sympathetic paralysis
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| The ear lesions are reported how | same as a clock
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| What is vertigo? | a false sense of rotational motion; it points to an inner ear lesion, CN VIII lesion, or a brain lesion
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| Ménière disease | is suspected when tinnitus is associated with hearing loss and vertigo
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| Weber and Rinne test | air conduction is better than bone conduction and twice as long as bone- Rinee. If air is worse, there is conduction issue. Weber’s- on top of head- should hear equally in middle
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| Viral vs allergic rhinitis | both swollen but in allergies it’s pale vs red
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| Otoscope for kids | down and out- adults up and back
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| Test question- Epiglottitis-bacterial | Child w/acute, onset ↑fever, sore throat, drooling, difficulty breathing- not eat- difficult swallowing, Hot pto voice. Hyperextended neck, open- mouthed breathing, tripod position Stridor, cyanosis, tachycardia, tachypnea- NO COUGH ddx croup
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| Acute tonsillitis | Red swollen tonsils, Crypts filled with purulent exudate, Enlarged anterior cervical LNs, Palatal petechiae- strep- Sore throat, fever, malaise-Fetid breath-May have associated abdominal pain & headache- amoxicillin or chronic do tonsillectomy
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| Strep can cause what | pharyngitis or tonsillitis and mono
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| Peritonsillar abscess | tonsil pushed from the inside,Dysphagia and drooling, Severe sore throat w/ pain radiating to ear;pain worse on one side, & on swallowing, Malaise , fever, Unilateral red, swollen tonsil and adjacent soft palate, augmentin/zosyn, tonsillectomy- drain pus
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| Benign paroxysmal positional vertigo | seconds
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| Vertebro-basilar insufficiency, migraine- vertigo | minutes
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| Ménière disease/vertigo | hours
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| Viral labyrinthitis/vertigo | days
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| Signs of acute otitis media | red, bulging, IMMOBILITY- use air in otoscope- purulent effusion, Painful hemorrhagic vesicles, blood-tinged ear discharge, conductive hearing loss- Seen in mycoplasma and viral infections and bacterial otitis media
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| Bullous Myringitis | viral otitis media or mycoplasma pneumonia- painful vesicle on ear canal or TM- test for cold agglutinins
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| External or middle ear hearing issue | conduction problem voice does not get louder- more in the young and can see it in the ear canal
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| Sensorineural hearing loss | cochlear issue- not processed correctly have louder voice
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| Weber and Rinne can be done separately? | no, have to do together
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| Normal for weber and rinne | weber is heard midline or equally in both ears- and rinne is AC is better than BC
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| Conductive hearing loss example- foreign body in right ear | sound will not make it through the air but will make it through the bone BC > AC in affected ear for rinne (sensory neural you will not hear whatsoever)
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| Weber test for the right ear- has foreign body | you will hear it better in the right ear (affected ear) :? Whatever for Weber- sensorineural, you will not hear anything.
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| Angular cheilitis | softening of skin angles of the mouth→fissuring d/t folate and iron deficiency
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| What’s important about pharyngitis? | make sure it’s not beta hemolytic strep that causes rheumatic fever and glomerulonephritis do rapid strep test
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| Candidiasis thrush | CHEESY- if it scrapes off
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| Oral hairy leukoplakia | doesn’t scrape off precancerous This condition is caused by Epstein-Barr virus infection when seen in HIV/AIDS.
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| Gingival hyperplasia | caused by phenytoin, CCB cyclosporin- stop the offending drug
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| Fissure tongue is seen in | elderly
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| Strawberry tongue | Enlargement of tongue papillae- caused by Group A Beta Hemolytic- Streptococci (GABHS), Kawasaki disease, and vit B12 deficiency. Rapid strep test is diagnostic for GABHS
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| Smooth tongue/ atrophic glossitis | deficiency of riboflavin,niacin, folic acid, vit. B12, pyridoxine, or iron. Seen also in treatment with chemotherapy
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| Otitis externa (malignant) | Intense right ear pain (started with itching of the ear canal after swimming) d/c coming from the right ear, started as watery, now purulent/smelly- tender pinna and tragus- if life threatening it’s malignant- pseudomonas
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| Acute otitis media | no mobility- red swollen, clear rhinorrhea, sore throat, fever, non-productive cough, tonsils enlarged- Tympanostomy tube- immobility of TM (air insufflation)-Most accurate test: tympanocentesis- culture/sensitivity (ONLY for recurrent cases)
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| Cleft palate | Difficult sucking, Failure to gain weight
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| Pharyngitis | exudate on the tonsils, is it bad strep?--> Rapid strep test: for the nephritogenic strains of strep- If positive give penicillin (amoxicillin)- enlarged ant. Cervical lymph nodes
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| Infectious mononucleosis | Enlarged Posterior cervical LN mono test- give analgesics/steroids- caused by Epstein-Barr virus
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| Child with asthma | oral candidiasis- d/t steroids advise to rinse mouth
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| Fracture of the base of the skull | hematoma over the mastoid process- Associated with blood in the TM- do head CT
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| Aphthous ulcers | (canker sores) Shallow, tender ulcers on labial, buccal, gingival mucosa
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| Angular cheilitis | Painful red fissures at the angle of the mouth- d/t HIV, can be fungal- oral fluconazole- folate and iron deficiency
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| Warning s/s for headache | progressive, Sudden onset “thunderclap,” after 50, change of position, valsalva maneuver,fever, night sweats or weight loss, presence of cancer, HIV infection, or pregnancy, trauma, pattern change, papilledema, neck stiffness, or focal neurologic deficits
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| Neck examination | Inspect for swellings/masses, Palpate for lymph nodes, Examine for tracheal shift, Examine the thyroid
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| Test question Tracheal shift exam | By inspection& palpation, Deviation could be due to: a mediastinal mass, atelectasis/lung collapse, or a large pneumothorax
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| Enlarged supraclavicular node (esp. the Lt.) suggests | possible metastasis from a thoracic or an abdominal malignancy bad sign
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| A tender lymph node means | infection
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| A hard non-moveable lymph node means | cancer/malignancy
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| Retrosternal goiters | when goiter is huge and extends down into he thorax- can block the inlet- might not always be palpable, can cause hoarseness, shortness of breath, stridor or dysphagia- ask pt to Neck hyperextend and elevate arms= flushing- Pemberton sign
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| Goiter is | a big gland- have to do a blood test to differentiate whether it’s hypo or hyper
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| Thyroiditis | tender thyroid
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| Caput succedaneum | Significant scalp edema as a result of compression during transit through birth canal. Edema does cross suture lines
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| Hydrocephalus | enlarged head, thinning of the scalp with dilated scalp veins, “sunsetting sign.”
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| Pierre-Robin sequence | in baby- a triad of micrognathia, glossoptosis, and palatal clefting-retruded mandible
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| Test Fetal alcohol syndrome | acquired intellectual disability- poorly formed philtrum; widespread eyes, with inner epicanthal folds and mild ptosis; hirsute forehead; short nose; and relatively thin upper lip
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| Pregnancy and thyroid | hypertrophy of thyroid- increase the levo by 30%
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| Cluster headache | unilateral, more in males, sharp intense and severe, autonomic symptoms in the eye and nose- lacrimation, ptosis, myosis
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| Tension headache | band around your head
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| Migraine | starts around age 12-15, 1-2x week, n/v, throbbing, mostly unilateral
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| Analgesic rebound headache | Results from withdrawal of certain medications. The previous headache pattern will occur
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| Errors of refraction | glasses Due to sustained contraction of EOM. Around & over the eyes. Steady, aching, dull. Associated with eye fatigue and “sandy” sensations in eyes and redness of conjunctiva
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| Acute glaucoma | pain in the eye rather than headache- Sudden increase in IOP. Pain in and around one eye. Severe, steady, aching. Associated with blurred vision, halos around lights
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| Sinusitis headache | frontal sinuses above the eyes or over maxillary sinuses. Aching or throbbing. Often repetitive daily. Local tenderness, with nasal congestion, discharge and fever. Aggravated by coughing, sneezing, or jarring the head.
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| Meningitis | Generalized, steady, throbbing, severe headache that develops within a day. Associated with fever, stiff neck, photophobia, may be altered mental status
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| Subarachnoid hemorrhage | worst headache of my life- Generalized, very severe. Sudden in less than a minute. Associated N&V, loss of consciousness, neck pain. Possible prior neck symptoms from “sentinel leaks”.
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| Brain tumor | Variable locations. Aching, steady, dull pain worse on awakening. Associated seizures, hemiparesis, field cuts, personality changes, N&V, vision change, gait change. Aggravated by coughing, sneezing, sudden head movements, vasalva
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| Temporal giant cell arteritis | More in women. Localized near the temporal artery. Throbbing, severe. Tenderness over the temporal artery. Associated fever (50%), jaw claudication (50%), loss of vision (20%). Aggravated by movements of neck& shoulders
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| Post concussion headache | Often localized to the injured area. Dull, aching, constant. Within 7-90 days of injury and may last up to a year. Associated with drowsiness, poor concentration, confusion, memory loss, blurred vision, fatigue, irritability.
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| Trigeminal neuralgia | Over cheek, jaws. Shock-like, stabbing, burning, severe. Abrupt onset and recurrent course. Aggravated by touching certain areas of the lower face, chewing, talking, brushing teeth.
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| Bell palsy | Left facial palsy (cranial nerve VII). Facies include asymmetry of one side of the face, eyelid not closing completely, drooping lower eyelid and corner of mouth, and loss of nasolabial fold
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| Hot thyroid nodules are | almost always benign takes a lot of radioactive iodine
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| Multinodular goiter | describe the condition where at least two detectable nodules are palpable within the thyroid tissue- firm and sometimes calcify
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| Diffuse goiter | both lobes can enlarge but stay smooth and non-nodular- may feel constraining- may cause tracheal deviation and difficulty swallowing
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| a large goiter extends from the neck into the superior mediastinum through the thoracic inlet is called | substernal thyroid
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| When a patient with a large substernal thyroid elevates his or her arms above the head, the thoracic inlet may obstruct. As a result, venous congestion and cyanosis/flushig of the face occurs and is called | Pemberton’s sign
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| Thyroglossal Duct Cyst | a tense, nontender, mobile, round mass in the midline of the neck at the level of the hyoid bone
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| Freely movable cystic mass in neck midline, Moves upward with tongue protrusion and swallowing, May have small opening in skin, with drainage of mucus, difficulty swallowing, tenderness, redness midline of neck of young pt | thyroglossal duct cyst
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| If you see ciliary flush | refer pt to an ophthalmologist
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| Best initial test for acromegaly and then most accurate test | initial→ Insulin-like growth factor level (IGF-1) (Growth hormone has a very short half-life and has its peak secretion in the middle of night during sleep)-Most accurate test: failure of a glucose infusion to suppress growth hormone levels
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| consensual reaction | constriction of the opposite illuminated
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| confrontation testing is done for what | visual fields- need to refer to ophthalmologist if there's a problem- any part missing? do wiggling test- need to do the Humphrey Visual Field- they do automated berimetric testing
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| superior rectus | eye goes up
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| superior oblique | down and inward-- cranial nerve 4
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| inferior rectus | down
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| lateral rectus | cranial nerve 6
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| Relative afferent pupillary defect (RAPD) or Marcus Gunn pupil | is a medical sign observed during the swinging-flashlight test whereupon the patient's pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye.
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| papilledema | hazy- optic disc- not clearly demarcated and blurry- hemorrhages
In optic neuritis, it’s blurred too, but there’s pain with movement, loss of central vision and with swinging light test, there’s deficiency
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