Blurred vision resident survival guide: Difference between revisions
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{{CMG}}; {{AE}}{{Wd}} | {{CMG}}; {{AE}}[[User:MoisesRomo|Moises Romo M.D.]], {{Wd}} | ||
'''''Synonyms and Keywords:''''' | '''''Synonyms and Keywords:''' blurry vision management, blurry vision diagnosis, blurry vision, treatment, blurry vision workup'' | ||
==Overview== | ==Overview== | ||
[[Blurred vision]] is very common [[visual]] complaint with [[ophthalmologic]] or [[neurologic]] conditions. | [[Blurred vision]] is a very common [[visual]] complaint with [[ophthalmologic]] or [[neurologic]] conditions. It is an inability to see small details clearly and sharply. Decreased [[visual]] clarity can develop gradually or suddenly depending on the cause of the symptom. Refractory errors are the major causes of [[blurred vision]] complaints. Therefore most of these [[vision]] issues can be corrected with [[glasses]]. Any disease affecting [[eyes]] can cause blurriness in [[vision]]. To guide the diagnosis of [[blurred vision]] it is important to know the details like duration, progression, near or farsighted, permanent or transient, uniocular or binocular, and associated symptoms. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life-Threatening Causes=== | ||
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | ||
* [[Eye Trauma]] | *[[Eye Trauma]] | ||
* [[Glaucoma]] | *[[Glaucoma]] | ||
* [[Stroke]] | *[[Stroke]] | ||
* [[Brain tumor]] | *[[Brain tumor]] | ||
* [[Retinal detachment]] | *[[Retinal detachment]] | ||
* [[Optic neuritis]] | *[[Optic neuritis]] | ||
* [[Transient ischemic attack]] | *[[Transient ischemic attack]] | ||
===Common Causes=== | ===Common Causes=== | ||
| Line 31: | Line 31: | ||
==Diagnosis== | ==Diagnosis== | ||
Shown below is an algorithm summarizing the diagnosis of blurred vision according the | Shown below is an algorithm summarizing the diagnosis of blurred vision according to the American Academy of Ophthalmology guidelines.<ref name="urlBlurriness - American Academy of Ophthalmology">{{cite web |url=https://www.aao.org/eye-health/symptoms/blurriness-2 |title=Blurriness - American Academy of Ophthalmology |format= |work= |accessdate=}}</ref><ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="ShingletonO'Donoghue20003">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref> | ||
{{Family tree/start}} | |||
{{Family tree | | | | | | | | | A01 | | | |A01= '''Individual with blurry vision''' }} | |||
{{Family tree | | | | | | | | | |!| | | | | }} | |||
{{Family tree | | | | | | | | | B01 | | | |B01= '''Characterize'''<br> • Onset (sudden or gradual)<br> • Duration of [[symptoms]]<br> • Progression<br> • Near or far [[sight]]<br> • Binocular or uniocular<br> • Permanent or transient}} | |||
{{Family tree | | | | | | | | | |!| | | | | }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= Associated [[symptoms]] }} | |||
{{Family tree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | |||
{{Family tree | | C01 | | | | | C02 | | | | | C03 |C01='''[[Symptoms]] suggestive of eye [[etiology]]'''<br> • [[Dry eye]]<br> •EOM [[paralysis]]<br> • [[Headache]] <br> • [[Double vision]]<br> • [[Red eyes]]<br> • Pain in the [[eyes]]<br> • Squinting|C02= '''Non-specific [[symptoms]]'''<br> • [[Epiphora|Tearing]] <br> • [[Rhinorrhea]] <br> • [[Fatigue]]<br> • [[Nausea]] <br> • [[Lethargy]]|C03= '''[[Symptoms]] suggestive of [[neurologic]] [[etiology]]''' <br> • Transient previous episodes<br> • Unilateral [[headache]]<br> • [[Nausea]]/[[vomiting]]<br> • [[Loss of consciousness]]<br> • [[Altered mental status]] }} | |||
{{Family tree | | |`|-|-|-|-|-|-|+|-|-|-|-|-|-|'| }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= Inquire about past [[medical]] [[risk factors]] }} | |||
{{Family tree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | |||
{{Family tree | | C01 | | | | | C02 | | | | | C03 | |C01= '''Other causes''' <br> • [[Hypoglycemia]]<br> • [[Medication|Medication]] side effects or overuse<br> • [[Infectious]] [[diseases]]<br> • [[Endocrinologic]] [[diseases]]<br> • [[Hyperviscosity]] <br> • [[HIV]]<br> • [[Poisoning]] (mushrooms)|C02= '''[[Ophthalmologic]] [[diseases]]''' <br> • [[Keratitis]]<br> • Refractory [[blurred vision]]<br> • [[Diabetic retinopathy]]<br> • [[Optic neuritis]]<br> • [[Macular degeneration]]<br> • [[Iritis]]|C03= '''[[Neurologic]] disorders''' <br> • AV [[malformations]] (AVF)<br> • Previous history of [[migraine]]s<br> • [[Diagnosis]] of [[MS]]<br> • [[Trauma]] leading to [[concussion]] or [[hematoma]]<br> • [[Stroke]] }} | |||
{{Family tree | | |`|-|-|-|-|-|-|+|-|-|-|-|-|-|'| }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= Examine the patient }} | |||
{{Family tree | | | | | | | | | |!| | | | | }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= '''[[Vital signs]]''' <br> • [[Fever]] (when [[infection]] suspected)<br> • [[Heart rate]] ([[tachycardia]], [[bradycardia]])<br> • [[Blood pressure]] ([[hypertension]])<br> • [[Tachypnea]]<br> '''General appearance'''<br> • Pale<br> • [[Diaphoretic]]<br> • Severe distress<br> '''[[Neck]]'''<br> • [[JVD]] <br> '''[[Eye]] examination'''<br> • Dilated [[fundus]] exam<br> • [[Slit lamp]] examination<br> • [[Visual acuity]]<br> • Dry or irritated [[eyes]]<br> • Improvement of [[vision]] <br> [[Ear]], [[nose]] and [[throat]]<br> '''Palpate temporal area to rule-out [[temporal arteritis]]'''<br> '''[[Neurologic]] exam if necessary'''}} | |||
{{Family tree | | | | | | | | | |!| | | | | }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= '''Order labs and tests according to suspected [[etiology]]''' <br> • CBC<br> • Random and fasting [[blood sugar]] (repeat test if initial measure is elevated)<br> • [[Partial thromboplastin time|Partial thromboplastin time (PTT)]]<br> • [[Prothrombin time (PT)]]<br> • [[ESR]] (important to rule-out [[temporal arteritis]])<br> • [[EEG]] (if [[seizures]] are suspected)}} | |||
{{Family tree | | | | | | | | | |!| | | | | }} | |||
{{Family tree | | | | | | | | | B01 | | |B01= '''Verify if [[blurred vision]] has any findings suggestive of [[Ophthalmology|ophthalmologic]] [[etiology]]''' <br> • Squint<br> • [[Dry eye]]<br> • [[Pain]]<br> • Refractory error<br> • Floaters<br> • [[Conjunctivitis]] ([[red eye]]) }} | |||
{{Family tree/end}} | |||
==Treatment== | ==Treatment== | ||
Treatment of blurry vision will vary depending on the underlying cause: | |||
== | |||
*To view the [[treatment]] of [[conjunctivitis]] [[Conjunctivitis medical therapy|click here]]. | |||
*To view the [[treatment]] of [[optic neuritis]] [[Optic neuritis|click here]]. | |||
*To view the [[treatment]] of [[iritis]] [[Iritis|click here]]. | |||
*To view the [[treatment]] of [[macular degeneration]] [[Macular degeneration medical therapy|click here]]. | |||
*To view the [[treatment]] of [[keratitis]] [[Keratitis|click here]]. | |||
*To view the [[treatment]] of [[Sjögren's syndrome|Sjogren's syndrome]] [[Sjögren's syndrome|click here]]. | |||
*To view the [[treatment]] of [[EOM paralysis]] [[EOM paralysis| click here]]. | |||
*To view the [[treatment]] of [[glaucoma]] [[Glaucoma medical therapy|click here]]. | |||
*To view the [[treatment]] of [[presbyopia]] [[Presbyopia|click here]]. | |||
*To view the [[treatment]] of [[Migraine|migraines]] [[Migraine medical therapy|click here]]. | |||
==Dos== | |||
* | *Ask the patient for the time of onset and how he/she first noticed the [[symptoms]].<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | ||
*Ask if the presentation was sudden in onset, or if it was gradual.<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
*Ask if it occurred with or without [[pain]].<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref><ref name="Roth Thisted1996">{{cite journal|last1=Roth|first1=Steven|last2= Thisted|first2=Ronald A.|last3= Erickson|first3=John P.|last4= Black|first4=Susan|last5= Schreider|first5=Bruce D.|title=Eye Injuries after Nonocular Surgery|journal=Anesthesiology|volume=85|issue=5|year=1996|pages=1020–1027|issn=0003-3022|doi=10.1097/00000542-199611000-00009}}</ref> | |||
*Ask if the [[Blurred vision|blurry vision]] was unilateral or bilateral.<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
*Ask for any associated conditions or events, such as auras before [[migraines]] or focal [[Neurological|neurologic]] [[signs]].<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
*Ask if any history of blunt [[trauma]], penetrating [[injury]], or exposure to a [[foreign body]].<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref><ref name="Roth Thisted19962">{{cite journal|last1=Roth|first1=Steven|last2= Thisted|first2=Ronald A.|last3= Erickson|first3=John P.|last4= Black|first4=Susan|last5= Schreider|first5=Bruce D.|title=Eye Injuries after Nonocular Surgery|journal=Anesthesiology|volume=85|issue=5|year=1996|pages=1020–1027|issn=0003-3022|doi=10.1097/00000542-199611000-00009}}</ref> | |||
*Ask for the recent use of any [[medications]] such as [[steroids]] (systemic, injectable, topical, or inhaled), as these may be associated with [[cataracts]], [[glaucoma]], and [[keratitis]].<ref>{{cite journal|doi=10.1016/S2214-109X(17)30393-5 pmid:29032195}}</ref> | |||
*Ask for any family history of [[glaucoma]] or [[macular degeneration]].<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
*Ask for any personal history of [[symptoms]] similar to the current ones.<ref name="ShingletonO'Donoghue2000">{{cite journal|last1=Shingleton|first1=Bradford J.|last2=O'Donoghue|first2=Mark W.|title=Blurred Vision|journal=New England Journal of Medicine|volume=343|issue=8|year=2000|pages=556–562|issn=0028-4793|doi=10.1056/NEJM200008243430807}}</ref><ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
*Test [[eyes]] one at a time; the patient should have their contact lenses or [[glasses]] in place if these are normally worn.<ref name="Tessler2000">{{cite journal|last1=Tessler|first1=Howard H|title=Principles and Practice of Ophthalmology,|journal=Survey of Ophthalmology|volume=45|issue=3|year=2000|pages=259|issn=00396257|doi=10.1016/S0039-6257(00)00166-1}}</ref> | |||
==Don'ts== | ==Don'ts== | ||
* | *Do not use topical [[corticosteroids]] regularly, since they may be associated with the development of [[cataracts]], [[glaucoma]], and reactivation of [[herpes simplex virus]] [[infection]].<ref name="pmid10680416">{{cite journal |vauthors=To TQ, Townsend JC |title=Ocular toxicity of systemic medications: a case series |journal=Optometry |volume=71 |issue=1 |pages=29–39 |date=January 2000 |pmid=10680416 |doi= |url=}}</ref> | ||
==References== | ==References== | ||
{{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | {{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | ||
[[Category:Up-To-Date]] | |||
Latest revision as of 21:23, 14 January 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D., Wajeeha Aiman, M.D.[2]
Synonyms and Keywords: blurry vision management, blurry vision diagnosis, blurry vision, treatment, blurry vision workup
Overview
Blurred vision is a very common visual complaint with ophthalmologic or neurologic conditions. It is an inability to see small details clearly and sharply. Decreased visual clarity can develop gradually or suddenly depending on the cause of the symptom. Refractory errors are the major causes of blurred vision complaints. Therefore most of these vision issues can be corrected with glasses. Any disease affecting eyes can cause blurriness in vision. To guide the diagnosis of blurred vision it is important to know the details like duration, progression, near or farsighted, permanent or transient, uniocular or binocular, and associated symptoms.
Causes
Life-Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Age related macular degeneration
- Cataract
- Diabetic retinopathy
- Myopia
- Migraines
- Dry eyes
- Presbyopia
- Need for corrective lenses
- Uveitis
- iritis
- Adverse effect (medicine)
Diagnosis
Shown below is an algorithm summarizing the diagnosis of blurred vision according to the American Academy of Ophthalmology guidelines.[1][2][3]
| Individual with blurry vision | |||||||||||||||||||||||||||||||||||||
| Characterize • Onset (sudden or gradual) • Duration of symptoms • Progression • Near or far sight • Binocular or uniocular • Permanent or transient | |||||||||||||||||||||||||||||||||||||
| Associated symptoms | |||||||||||||||||||||||||||||||||||||
| Symptoms suggestive of eye etiology • Dry eye •EOM paralysis • Headache • Double vision • Red eyes • Pain in the eyes • Squinting | Non-specific symptoms • Tearing • Rhinorrhea • Fatigue • Nausea • Lethargy | Symptoms suggestive of neurologic etiology • Transient previous episodes • Unilateral headache • Nausea/vomiting • Loss of consciousness • Altered mental status | |||||||||||||||||||||||||||||||||||
| Inquire about past medical risk factors | |||||||||||||||||||||||||||||||||||||
| Other causes • Hypoglycemia • Medication side effects or overuse • Infectious diseases • Endocrinologic diseases • Hyperviscosity • HIV • Poisoning (mushrooms) | Ophthalmologic diseases • Keratitis • Refractory blurred vision • Diabetic retinopathy • Optic neuritis • Macular degeneration • Iritis | Neurologic disorders • AV malformations (AVF) • Previous history of migraines • Diagnosis of MS • Trauma leading to concussion or hematoma • Stroke | |||||||||||||||||||||||||||||||||||
| Examine the patient | |||||||||||||||||||||||||||||||||||||
| Vital signs • Fever (when infection suspected) • Heart rate (tachycardia, bradycardia) • Blood pressure (hypertension) • Tachypnea General appearance • Pale • Diaphoretic • Severe distress Neck • JVD Eye examination • Dilated fundus exam • Slit lamp examination • Visual acuity • Dry or irritated eyes • Improvement of vision Ear, nose and throat Palpate temporal area to rule-out temporal arteritis Neurologic exam if necessary | |||||||||||||||||||||||||||||||||||||
| Order labs and tests according to suspected etiology • CBC • Random and fasting blood sugar (repeat test if initial measure is elevated) • Partial thromboplastin time (PTT) • Prothrombin time (PT) • ESR (important to rule-out temporal arteritis) • EEG (if seizures are suspected) | |||||||||||||||||||||||||||||||||||||
| Verify if blurred vision has any findings suggestive of ophthalmologic etiology • Squint • Dry eye • Pain • Refractory error • Floaters • Conjunctivitis (red eye) | |||||||||||||||||||||||||||||||||||||
Treatment
Treatment of blurry vision will vary depending on the underlying cause:
- To view the treatment of conjunctivitis click here.
- To view the treatment of optic neuritis click here.
- To view the treatment of iritis click here.
- To view the treatment of macular degeneration click here.
- To view the treatment of keratitis click here.
- To view the treatment of Sjogren's syndrome click here.
- To view the treatment of EOM paralysis click here.
- To view the treatment of glaucoma click here.
- To view the treatment of presbyopia click here.
- To view the treatment of migraines click here.
Dos
- Ask the patient for the time of onset and how he/she first noticed the symptoms.[2][4]
- Ask if the presentation was sudden in onset, or if it was gradual.[2][4]
- Ask if it occurred with or without pain.[2][4][5]
- Ask if the blurry vision was unilateral or bilateral.[2][4]
- Ask for any associated conditions or events, such as auras before migraines or focal neurologic signs.[2][4]
- Ask if any history of blunt trauma, penetrating injury, or exposure to a foreign body.[2][4][6]
- Ask for the recent use of any medications such as steroids (systemic, injectable, topical, or inhaled), as these may be associated with cataracts, glaucoma, and keratitis.[7]
- Ask for any family history of glaucoma or macular degeneration.[2][4]
- Ask for any personal history of symptoms similar to the current ones.[2][4]
- Test eyes one at a time; the patient should have their contact lenses or glasses in place if these are normally worn.[4]
Don'ts
- Do not use topical corticosteroids regularly, since they may be associated with the development of cataracts, glaucoma, and reactivation of herpes simplex virus infection.[8]
References
- ↑ "Blurriness - American Academy of Ophthalmology".
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Shingleton, Bradford J.; O'Donoghue, Mark W. (2000). "Blurred Vision". New England Journal of Medicine. 343 (8): 556–562. doi:10.1056/NEJM200008243430807. ISSN 0028-4793.
- ↑ Shingleton, Bradford J.; O'Donoghue, Mark W. (2000). "Blurred Vision". New England Journal of Medicine. 343 (8): 556–562. doi:10.1056/NEJM200008243430807. ISSN 0028-4793.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Tessler, Howard H (2000). "Principles and Practice of Ophthalmology,". Survey of Ophthalmology. 45 (3): 259. doi:10.1016/S0039-6257(00)00166-1. ISSN 0039-6257.
- ↑ Roth, Steven; Thisted, Ronald A.; Erickson, John P.; Black, Susan; Schreider, Bruce D. (1996). "Eye Injuries after Nonocular Surgery". Anesthesiology. 85 (5): 1020–1027. doi:10.1097/00000542-199611000-00009. ISSN 0003-3022.
- ↑ Roth, Steven; Thisted, Ronald A.; Erickson, John P.; Black, Susan; Schreider, Bruce D. (1996). "Eye Injuries after Nonocular Surgery". Anesthesiology. 85 (5): 1020–1027. doi:10.1097/00000542-199611000-00009. ISSN 0003-3022.
- ↑ . doi:10.1016/S2214-109X(17)30393-5 pmid:29032195 Check
|doi=value (help). Missing or empty|title=(help) - ↑ To TQ, Townsend JC (January 2000). "Ocular toxicity of systemic medications: a case series". Optometry. 71 (1): 29–39. PMID 10680416.