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Matt Edmunds Clinical Lecturer / Specialty Registrar Academic Unit of Ophthalmology University of Birmingham What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not when is it acceptable to ask an optician to help before referral? Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy? What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow morning/clinic? How should we access these/ advice OOH? The red eye What to do about dry eyes/ watering eyes/ blepharitis What to do about floaters and/ or flashes What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage? What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not when is it acceptable to ask an optician to help before referral? What mistakes do we make in our historytaking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage? Broad generalisation……. Most patients will present with ‘red eye’ Significant proportion of red eye can be managed in primary care ▪ Whereas most ‘non-red eye’ pathology is likely to require secondary care input Limitations Not much training in eyes ▪ Year 4 MBChB at UoB: 5 days ophthalmology ▪ Few GP VTS posts in ophthalmology across Midlands Lack of equipment Pressurised for time Acute or gradual onset? One or both eyes? Is vision affected? Discharge? Purulent? Watery? Pain? Sensitivity to light? Contact lens wearer? Previous episodes? Industrial injury? Associated systemic symptoms? Visual acuity (and idea of any recent changes) Pupil reactions Eye movements Gross observations Lid swelling and discharge / lash crusting Distribution of any redness / obvious eye lesions Corneal staining with fluorescein / FB Comment on anterior chamber / cornea ▪ TIP: Ophthalmoscope on +20D Optic disc / fundus Not easy with ophthalmoscope Please, at least try Can use book eg BNF/BMJ if snellen chart not available on wards Snellen charts needed in practice Hypermetrope (convex) Myope (concave) Almost emmetropic If unable to read top line on Snellen chart: If unable to read top line on Snellen chart: Count fingers? (CF) If unable to read top line on Snellen chart: Count fingers? (CF) Hand movements? (HM) If unable to read top line on Snellen chart: Count fingers? (CF) Hand movements? (HM) Perceive light? (PL) If unable to read top line on Snellen chart: Count fingers? (CF) Hand movements? (HM) Perceive light? (PL) No light perception (NLP) Upper punctum Caruncle Conjunctiva Limbus Iris Cornea Lower punctum Superior 12 Temporal 9 3 6 Inferior Nasal Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy? Dark room Dim ophthalmoscope light Smaller pupil setting Get patient to look into distance ?Pharmacologically dilate pupils Mainly: have low expectations! What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow morning/clinic? How should we access these/ advice OOH? There may be disparity in sense of urgency You may get a different response to a referral at different times of the day – appropriate Please don’t ‘opt out’ of ophthalmology Please always send a brief referral letter Same day Could wait until next day Uveitis Zoster with eye involvement Scleritis If not resolving as expected Acute glaucoma Temporal arteritis (with definite ophthalmic symptoms) Painful eye after cataract surgery Painful or red eye after corneal graft Painful or red eye in contact lens wearer Orbital cellulitis Suspected corneal infections Conjunctivitis Episcleritis Via out-patient clinic Blepharitis / Dry eye / Chronic grittiness or soreness Entropion Ectropion GCA with eye involvement Temporal pain / jaw claudication / night sweats / weight loss / transient visual obscurations / visual disturbance CRAO within past 24 hours Sudden and persistent unilateral painless loss of vision Orbital cellulitis Significant chemical injury Suspected penetrating eye injury / significant trauma Retrobulbar haemorrhage Acute glaucoma Suspected endophthalmitis Painful red eye / reduced vision / recent intra-ocular intervention Suspected retinal tear / detachment Suspected vitreous haemorrhage Suspected optic neuritis (unless GCA) New onset diplopia Unless 3rd nerve palsy / complex CN palsy Most trauma Most red eye pathology Open for walk-in patients 365 days / year No referral necessary Accept all patients 9am – 7pm Mon-Sat / 9am-6pm Sun and Bank Holidays Urgent care clinic available via triage nurse Also have acute referral clinics at RHH / SGH Limited number of clinic slots Accept direct GP referrals No emergency eye clinic at QEH On-call registrar via telephone overnight Discuss emergency patients Review patients on eye ward if necessary (Sheldon Block, City Hospital, Dudley Road) Senior SpR (4th on-call) will review patients in peripheral units if necessary Contact triage nurse at BMEC Call on-call SpR (2nd or 4th on-call) at BMEC Send to BMEC eye casualty With a letter If patient will arrive before closing time (7pm) The red eye! What to do about dry eyes/ watering eyes/ blepharitis Up to 80% of eye casualties present with a red eye Causes of a red eye can be roughly divided into two groups Pain +/- blurring of vision No pain and normal vision Most red eyes are due to conjunctivitis / blepharitis / dry eye If you can confidently exclude ‘serious’ pathology Oc. Chloramphenicol 1.0% QDS Warm compresses Lid hygiene Lubricants PRN ▪ Celluvisc / Optive / Systane / Hyloforte / Xailin Olapatidine BD (Opatanol) for allergic disease Discuss / refer if not improving / resolving Pain +/- blurred vision Important differential diagnoses include: No pain Differential diagnoses include: Acute glaucoma Conjunctivitis Corneal infections Episcleritis Anterior uveitis (iritis) Subconjunctival Scleritis haemorrhage Eyelids Conjunctivitis Bacterial Viral Chlamydial Allergic Keratitis Bacterial (Marginal) Viral (Episcleritis) / scleritis Acute anterior uveitis (iritis) Angle closure glaucoma Orbit Orbital cellulitis Trauma Subconjunctival haemorrhage Corneal abrasion Corneal FB Chemical burn Chronic inflammation of the eyelid margins Causes Usually Staph aureus or epidermidis Associated with skin disease •Acne rosacea •Seborrhoeic dermatitis Symptoms Sore Gritty Occasionally red eyes Examination Complications Hyperaemic lid margins Conjunctivitis Crusts on lashes Marginal keratitis Blocked meibomian gland orifices Meibomian cysts Meibomian cysts Lid hygiene Warm compresses Gentle expression of lipids with a cotton tipped applicator Gentle lid cleaning with a solution of sodium bicarbonate Antibiotic ointment Lubricants Omega-3 Low dose tetracyclines Antibiotics Lipid soluble Protease inhibitors Ectropion In-turning of the lower lid Out-turning of the lower lid Cicatrising Bacterial Allergic Viral Chlamydial Causes Usually staphylococcus, streptococcus or haemophilus species Symptoms Slight discomfort Red, sticky eye(s) Visual acuity is not affected although slight blurring due to purulent exudation, which clears when discharge is blinked away Examination Generalised conjunctival injection with purulent discharge lashes may stick together Causes Usually staphylococcus, streptococcus or haemophilus species Symptoms Slight discomfort Red, sticky eye(s) Visual acuity is not affected although slight blurring due to purulent exudation, which clears when discharge is blinked away Examination Generalised conjunctival injection with purulent discharge lashes may stick together Complications Usually nil Treatment frequent antibiotic drops - instil hourly for 24 hours then qid for a week general hygiene by not sharing towels etc Causes Usually adenovirus (self-limiting, but can also affect cornea keratoconjunctivitis) Symptoms Red, watery eye(s) Gritty, uncomfortable feeling Vision unaffected unless the cornea is involved Generalised conjunctival injection with watery discharge Follicles (lymphoid aggregates) in the tarsal conjunctiva Petechial conjunctival haemorrhages Enlarged preauricular lymph node Associated URTI Complications Treatment Highly contagious • Risk of epidemics • Nosocomial transfer Nil May last several weeks Antibiotic drops to prevent secondary bacterial infection Small corneal opacities leading to photophobia and reduced vision General hygiene by not sharing towels etc Red, watery eye(s) Vision unaffected Gritty, foreign body sensation Chronic Follicular reaction Usually young adults Sexually acquired Requires systemic antibiotics Acute onset Red, itchy eye(s) Chemosis (conjunctival oedema) Vision unaffected Type 1 hypersensitivity reaction •Seasonal •Perennial Oral antihistamines Often settles spontaneously Sodium cromoglycate / Olapatidine Fungal Autoimmune Bacterial Viral An ophthalmic emergency Causes Large range of gram positive or negative organisms Predisposing factors include Corneal abrasion Contact lenses (usually soft extended wear) Topical steroids Corneal anaesthesia (e.g. previous herpes zoster ophthalmicus) Symptoms Red, sticky eye Pain Reduced vision Photophobia Examination Conjunctival injection with purulent discharge Corneal abscess (yellow/white area on cornea) May be activity (cells) in anterior chamber Complications Severe sightthreatening intraocular infection (endophthalmitis) Corneal perforation Loss of eye Treatment Admit •Scrape cornea •Gram stain •Culture and sensitivities Sterilisation phase • Hourly antibiotics (usually monotherapy with a fluroquinolone) day and night for 2 days • Hourly antibiotics by day for three days • Cycloplegics • Intraocular hypotensives • Sub-conjunctival injections to be AVOIDED Healing phase • Healing retarded in persistent inflammation • Judicious use of topical glucocorticoids • Treat ocular surface disease (dye eye, entropions, blepharitis) Causes Herpes simplex type I (commonest) Symptoms Examination Complications Reduced vision frequently Conjunctival injection Corneal scarring Unilateral red eye Classical branching dendritic (epithelial) ulcer staining with fluorescein May affect deeper corneal layers e.g. stroma (disciform keratitis) Pain Reduced corneal sensation Corneal perforation Photophobia Complications • Secondary bacterial infection • Ulcer may recur DO NOT USE STEROIDS • Geographical ulceration Treatment • Antiviral ointment (e.g. aciclovir) tapering over a few weeks • Dilate pupil Systemic disease Idiopathic Infective Anterior scleritis is commonest but posterior involvement also occurs Anterior scleritis is sub-divided into • Diffuse • Nodular • Necrotising Inflammation of the outer (white) coat of the eye and can be a severe destructive, sight-threatening disease Causes Symptoms Majority idiopathic Pain (may be so severe that it wakes the patient at night) 40% associated with a connective tissue or vasculitic disease, commonest being rheumatoid arthritis Red eye(s) Infections • Varicella Zoster • Acanthamoeba • Bacterial endotoxins May be recurrent Pain on EOM Deep red colouration of anterior sclera - may be diffuse or localised Visual acuity may be normal Scleral thinning associated with bluish/black discolouration from underlying uveal tissue Oral NSAIDs for mild cases Complications Topical steroids as supplementary therapy Visual loss Systemic corticosteroids/pulsed immunosuppression for severe cases Scleral thinning Perforation of the globe Optic disc and macular oedema Endophthalmitis (infection inside the eye) Uveitis Uveitis cannot be accurately diagnosed without the aid of a slit-lamp Causes Symptoms • Majority unknown, occurs usually in 20-50 year age group • May be associated with a systemic disease e.g HLA-B27, sarcoidosis • May be associated with an infection e.g. herpetic, TB • • • • • • Red eye (usually unilateral) Pain Blurred vision Photophobia NO discharge NOT sticky Circumcorneal conjunctival injection Keratic precipitates (inflammatory cells) on corneal endothelium Flare (albumin leakage from iris vessels) Inflammatory cells in the anterior chamber hypopyon if severe Miosis Posterior synechiae (adhesions between iris and lens) Complications May be associated with raised intraocular pressure (IOP) Treatment Dilate pupil to prevent ciliary spasm and break posterior synechiae May become chronic and develop secondary cataract +/- macular oedema leading to reduced vision Intensive topical steroids, initially 1-2 hourly then gradually reduce over next 4-6/52 The condition is likely to recur and in either eye In severe cases a subconjunctival injection of steroid +/mydricaine (dilating agent) is necessary Causes Symptoms Examination Complications High hyperopia Nausea / vomiting Hyperaemia +++ Rapid and complete visual loss Advancing cataract Painful red eye Fixed middilated pupil Aetiology is usually bilateral NOT related to POAG Hazy vision Hazy cornea Haloes around bright lights Epiphora Palpate the eye to approximate IOP What to do about floaters / flashing lights Don’t panic – most cases will be a PVD Could it be migraine?? If there is a retinal detachment – at BMEC: ‘Macula on’ – 24-48 hours ‘Macula off’ – 5-7 days Causes Spread of local infection • Sinusitis • Eyelis Symptoms Examination Complications Fever Engorged conjunctival vessels Optic nerve compression Painful red eye Conjunctival chemosis Exposure keratitis Eyelid swelling Restricted EOM Rapid and complete visual loss Reduced vision Proptosis Intra-cranial spread Diplopia RAPD At 5 pm on a Thursday afternoon……. 68 year-old woman Previous right eye retinal detachment 2 days history of left flashing lights / floaters Right VA 6/36, Left VA 6/9 Pupil reactions normal At 11 am on a Friday morning……. 76 year-old woman Hypermetrope ‘Optician says I have cataracts in both eyes’ 2 months intermittent left eye pain, redness and hazy vision Right VA 6/12, Left VA 6/24 Pupil reactions normal At 9 am on a Monday morning……. 26 year-old man Awoke this morning with a painful, red left eye ‘Short-sighted’ Slept in contact lenses overnight from Saturday Right VA 6/12, Left VA 6/18 (wearing old specs) Pupil reactions normal At 2 pm on a Monday afternoon……. 26 year-old man 1 week history of red, gritty eyes and discharge Partner had sore throat and ‘flu symptoms Baby daughter recently had red eyes Right VA 6/9, Left VA 6/9 Pupil reactions normal At 6 pm on a Tuesday afternoon……. 36 year-old man Recent nose bleeds and short of breath Difficulty with left hearing Past 3 days unable to sleep with painful, red right eye and some photophobia No response with paracetamol /ibuprofen Right VA 6/12, Left VA 6/9 Pupil reactions normal At 10 am on a Tuesday morning……. 76 year-old woman Feeling generally unwell, off food, losing weight, difficulty sleeping Night sweats 2 weeks Headache Right VA 6/9, Left VA 6/9 Pupil reactions normal Purulent discharge = bacterial infection Photophobia = keratitis, uveitis Reduced vision = keratitis, uveitis, angle closure glaucoma Pain = scleritis, angle closure glaucoma, keratitis, uveitis Hazy cornea = angle closure glaucoma, keratitis, uveitis Contact lens wearer and sticky eye = must exclude bacterial keratitis VA and pupil examination are crucial Refer any CL wearer with red eye or pain Become familiar with a limited range of lubricant drops and stick to them If giving drops >4x/day then they should be PF (preservative free) Please don’t prescribe ocular topical steroids in primary care – great potential for ‘disaster’ Please do provide topical steroids if ongoing eye review Squinting children Recent onset: refer urgently to eye cas Long-standing: refer to clinic Temporal arteritis No visual symptoms – refer to rheumatology Visual symptoms – refer to ophthalmology