Download 19.11.14 Common Eye Conditions in General Practice by Katy Wells

Eye conditions seen in GP
Katy Wells and Elizabeth Crowther
Aims
• Discuss common eye conditions seen in GP
• Discuss management of these conditions
• Ophthalmology emergencies and Red flags
• Pub quiz
Eye problems
• 2 million people in the UK
• 1 million blind or partially sighted
• 1.5% of GP consultations
• Significant cause of preventable disabilities
General Practice
Infective Conjunctivitis 44%
Allergic Conjunctivitis 15%
Meibomian Cyst 8%
Blepharitis 5%
Cataract 4.8%
Abrasion/ F body 3%
Glaucoma 2.3%
Stye 2%
Macular disease 1.1%
Ant Uveitis 1.1%
No abnormality 1.8%
Other conditions 11.9%
A&E
Foreign body 29%
Corneal abrasion 15%
Eye injury/trauma 15%
Infective Conjunctivitis 9%
Allergic Conjunctivitis 3%
Lid inflammation 3%
Other conditions 26%
The Armoury….
• Vision testing chart
• Good light source with magnifier (and, ideally, blue light source)
• Proxymethacaine 0.5% with fluorescein 0.25% drops or fluoret strips and saline
drops
• Chloramphenicol ointment 1%
• Cotton buds
• Eye pads
• Tape
• Direct ophthalmoscope
• Tropicamide/Cyclopentolate (parasympathetic antagonists) /phenylephrine
(sympathetic agonist)
• Patient information leaflets
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Scenario 1
This 42 yr old patient presents with a 2 day Hx/o gritty, red left eye which has become sticky
over the last 24 hrs. His right eye doesn’t feel right today as well. His vision is normal.
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What is the diagnosis and etiology?
What are the clinical features you can see?
What other similar conditions should you differentiate it from?
How would you treat this patient?
Bacterial Conjunctivitis
Acute bacterial- Unilateral or bilateral
Sticky discharge
Papillae
Staphylococcus aureus in adults,
Streptococcus pneumoniae and Haemophilus
influenzae infections are more common causes in children.
Self limiting BUT Topical abxs: chloramphenicol,
ciprofloxacin, ofloxacin
>1 week refer
Hyperacute bacterial conjunctivitis - Neisseria gonorrhoeae,
sudden onset, progresses rapidly, leading to corneal
perforation.
Copious, purulent discharge; pain; and diminished vision loss.
Refer!
Viral conjunctivitis
Dilated vessels
No discharge/pain/photophobia/visual loss
Follicles
Pre-auricular lymphadenopathy
Adenovirus
1-2 weeks
Highly contagious
Hand hygiene
Cold artificial tears
Refer:
Corneal involvement
Suspected herpetic infection
Allergic
Bilateral and seasonal
Allergic
Itchy/swollen eyelids
Atopic history
O/E Injected conjunctiva, chemosis
Avoid allergens
Artificial tears
Topical antihistamine. Severe-steroid eye drops
Refer-persistent symptoms, vision is affected
Scenario 2
• This 68 yr old patient presented to his GP with eye irritation and redness
often worse when his central heating is on.
Keratoconjuctivitis sicca/ Dry eye syndrome
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Inflammation of conjunctiva and cornea
Decreased tear production or poor quality.
Symptoms worsened by activities with reduced rate of blinking/dry/dusty environment
RF’s/ increased age, female sex, medications (e.g., anticholinergics), and some medical
conditions.
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If Sjögren syndrome is suspected (dry mouth, +other body parts=Sicca syndrome), test for
autoantibodies.
Environmental awareness, Artificial tears, lubricants, steroids
Scenario 3
• This 21 yr old patient presented to his GP with a red painful swelling over his
eye lid
Hordeolum and Chalazion
Hordeolum (ie, stye)
• localized infection involving hair follicles of the eyelashes,
- Zeiss or Moll sebaceous glands (ie, external hordeolum)- most common, staph aureus
- meibomian glands (ie, internal hordeolum)
• painful, erythematous, and localized.
• Chloramphenicol qds 1 week, warm compress. If cellulitis PO abxs
Chalazion
• Following internal stye, painless granuloma of the meibomian glands.
• Most resolve, topical abx, incision and curettage
• Under age 7, risk of amblyopia, refer early
Scenario 4
65 yr old lady with rosacea presents with dry,
flaky, itchy eyes. This is the 3rd time this year she
has presented.
BLEPHARITIS
• Inflammatory eyelid condition
• Red rimmed, thickened lid margins +/- mild to severe crusting on the eyelashes
• Blocked or oozing meibomian glands
• Chronic staphylococcal infection
• It can cause secondary conjunctivitis, dry eye, small corneal ulcers.
• Closely associated with seborrhoeic dermatitis and rosacea.
Treatment
• Eyelid hygiene, gentle lid massage, and warm compresses- indefinitely
• Fusidate eye drops, steroid ointment, systemic tetracycline
Scenario 5
This 29 yr old female presented with a 2 day hx of pain, redness, intolerance to
light, excessive watering and blurred vision
Acute Iritis (anterior uveitis)
• Young,middle aged women
• Acute onset
• Associated with the HLA-B27 allele in 30%
• Corneal rejection or infection-TB, Syphillis
Symptoms
• dull ache within the eye
• severe photophobia
• slight reflex watering
• circumcorneal redness
• deposits on lower surface
• pupil - fixed, small at first
• normal intraocular pressure
Management
• Urgent referral
• Complications-posterior synechiae, glaucoma,cataract
Scenario 6
30 yr old lady presents with a red, mildly painful patch on her Right eye. Her
eye is watering slightly but her vision is normal. This is the second time she has
presented with this.
Episcleritis
• Episcleritis is a localized area of inflammation involving superficial layers of episclera
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Unilateral in 2:3 cases
• Self-limiting
Clinical Diagnosis:
• Redness disappears on compression and redness mobile on white of the eye with cotton bud, minimal
tenderness, no discharge
• Investigation of underlying causes is needed only for recurrent episodes ?Systemic diseases
Treatment
• Supportive care and use of artificial tears.
• Topical NSAIDs
• Refer if recurrent episodes, an unclear diagnosis (early scleritis), and worsening symptoms
Scenario 7
This 67 yr old patient presented with terrible pain in one eye and blurred
vision for over 12 hrs. He now has a throbbing headache, vomiting and
his vision is getting worse
Acute angle closure Glaucoma
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Uncommon, 0.1% patients
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Over 40, elderly long sighted women
Symptoms
• Pain, headache, nausea-vomiting
• Redness, photophobia,
• Reduced vision
• Haloes around lights
Examination
• Cornea looks hazy, pupil fixed and dilated, cicumcorneal
redness, hard eyeball
Treatment
• Urgent referral
• Meisosis to open drainage channels
• Risk-chronic gloucoma
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Scenario 8
70yr old lady comes to the surgery with a 2 month history of funny dots
moving across her vision and occasional bright lights.
She only really notices them when writing her letters or on sunny days.
Every time she tries to look at them they disappear and she thinks she
is ‘going mad’. Her vision seems fine.
Floaters and flashes
Flashes are caused by improper stimulation of the eye's retina, or the optic nerve, which the brain
interprets as light. Ie traction on retina
Black floaters: like spiders or tadpoles.
Vitreous Syneresis 25%
• Degeneration of the vitreous ( vitreous liquefaction),and visible collagen fibres
• These are not associated with flashes, reduced vision or defects in the visual field.
• Gradual onset
• 'settle' at the bottom of the eye
• More apparent when looking at something bright
• Reassure!
Posterior vitreous detachment
• Most common cause of flashes and floaters.
• 75% of those aged over 65 years
• Painless condition with no visual impairment
• Liquification-> reduction in volume-> falls away from retina
• Refer in a week!
When to suspect a retinal detachment?
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New onset of floaters
New onset of flashes
Sudden painless visual field loss.
Reduction in visual acuity, blurred or distorted vision.
A relative afferent pupillary defect if there is extensive detachment
Fundoscopy: loss of the red reflex, vitreous opacities, or detached retinal folds..
Children:
• Infants usually present with a white pupillary reflex or squint.
• In older children, most retinal detachment is secondary to trauma.
Red flags
• Sudden visual loss/blurring/ field defect
• Growing lumps esp pigmented on the lid
• Sudden onset diplopia/nystagmus
• Associated headache/scalp tenderness
• Flashing lights and floaters
• Red, painful eye, no clues
• Cellulitis in children
• Pupillary distortion/abnormality
• Abnormal fundus/disc with acute symptoms
• Hazy cornea
• Chemical injury
Things to think about…
• Psychological and social impact of poor eye sight.
• Environmental adaptions and community resources.
• How, when and who to screen for eye conditions.
• When and how to register a patient for blindness and partial sightedness,
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why would this be valuable?
DVLA driving regulations. www.DFT.gov.uk/DVLA/medical/ataglance.aspx
Pub QUIZ!!
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Further resources
• Royal National institute of blind people: www.nib.org.uk
• Royal college of opthalmologists: www.rcophth.ac.uk
• NICE guidance on glaucoma and type 2 diabetes- retinopathy
• e-GP
• UK vision strategy: www.vision2020uk.org.uk/ukvisionsrategy
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