Download WMH_2016_March

OPHTHALMOLOGY UPDATE
Ajay Bhatnagar
Consultant Ophthalmologist
Wolverhampton Eye Infirmary and Walsall Manor Hospital
Patient 1
• 70 year old female
• Floaters – few months
• VA – 6/6 BE
• Eye exam: unremarkable
• Amsler – “some distortion”
a. Urgent referral to eye
casualty (WEI)
b. Routine referral to WEI
c. Routine referral to WMH
d. Referral to wet AMD fast
track clinic
e. Any other
Patient 2
• 60 year old female
• c/o: sharp pain LE 2/12
(off and on)
• VABE 6/6. IOP WNL
• Eye exam WNL. Healthy discs
• Visual fields: defects BE
a. Urgent referral to eye
casualty (WEI)
b. Routine referral to WEI
c. Routine referral to WMH
d. Any other
Patient 3
• 50 year old male
• Reduced VA BE
(longstanding DR)
• Asymptomatic
• IOP: RE 23
LE 25
• Left disc looks glaucomatous
a. Urgent referral to eye
casualty (WEI)
b. Routine referral to WEI
c. Routine referral to WMH
d. Any other
Aim of today’s talk
• Refer the appropriate patient
• Appropriate time frame
• To the appropriate service
Some common conditions
• Cataract
• POLCV guidelines
• Direct cataract referral to hospital of patient’s choice
• Avoid referring using GOS18
• Glaucoma
• IOP referral refinement
• Refer – routine to WMH
• Known patients with glaucoma……refer to original
consultant at WMH / WEI
Some common conditions
• AMD
Fast track Macula Clinic (Fax to WEI)
• Symptoms
– Sudden decrease in VA
– Spontaneously reported recent onset distortion
• Signs
– Macular Hge / lipid / oedema
Routine referral to local eye clinic ??
Some common conditions
• Flashes and floaters
–
–
–
–
Self-reported, recent onset symptoms
Schaffer sign (“tobacco dust” in vitreous cavity)
Dilated fundus exam (digital wide field lens)
Refer to ARC if suspicion of retinal tear / detachment
• 24 hr referral –definite RD / retinal tear
• 72 hour referral – PVD related symptoms (<1/12 duration) with
pigment in vitreous cavity.
– Others
• ?? Routine referral
• Long standing symptoms / occ flash or floater
Some common conditions
• Reduction in vision:
– <48 hrs onset…….ARC (to be seen within 24 hrs)
• RD (includes retinal tear with no RD)
• Retinal vascular occlusion
• Optic neuritis / AION
• Unexplained sudden loss of vision
– <1/12 duration……ARC (to be seen within 72 hours)
– >1/12 duration …..refer to eye clinic (GOS 18)
Some common conditions
• Diplopia
– Monocular vs binocular
– Binocular diplopia
• <1/12 duration with no other symptoms – 72 hrs ARC
• >1/12 duration – refer via GOS 18
• Exception: Painful III cranial nerve palsy (ptosis,
limitation of EOM, dilated pupil)
Some common conditions
The Red Eye
• Common causes
– Lids
– Ocular surface
• Tear film
• Conjunctiva
• Cornea
– Intraocular causes
• Anterior uveitis (iritis)
• Acute angle closure glaucoma
Some common conditions
The Red Eye
• History
– Lids
• Sore, crusty eye lid margins/eyelashes. Long history (Blepharitis)
– Ocular surface
• Tear film – grittiness
(Dry eye)
• Conjunctiva – grittiness, watery / sticky disch, contact history
(Conjunctivitis)
• Cornea – Pain ++. h/o FB, Contact lens
(Ulcer / Abrasion)
– Intraocular causes
• Anterior uveitis (iritis) – pain++, tenderness, photophobia
• Acute angle closure glaucoma – pain++, reduced vision
Some common conditions
The Red Eye
• Examination
– Lids
• Crusty eye lid margins/eyelashes. Periocular skin
– Ocular surface
• Tear film – Tear meniscus……fluorescein dye
• Conjunctiva – generalised congestion, tarsal conj., cornea is clear
• Cornea – Corneal haze, fluorescein dye
– Intraocular causes
• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, hypopyon
• Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil
Some common conditions
The Red Eye
• Examination
– Lids
• Crusty eye lid margins/eyelashes. Periocular skin
– Ocular surface
• Tear film – Tear meniscus……fluorescein dye
• Conjunctiva – generalised congestion, tarsal conj., cornea is clear
• Cornea – Corneal haze, fluorescein dye
– Intraocular causes
• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon
• Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil
Some common conditions
The Red Eye
• Examination
– Lids
• Crusty eye lid margins/eyelashes. Periocular skin
– Ocular surface
• Tear film – Tear meniscus……fluorescein dye
• Conjunctiva – generalised congestion, tarsal conj., cornea is clear
• Cornea – Corneal haze, fluorescein dye
– Intraocular causes
• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon
• Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil
Some common conditions
Management
• Treatable in primary care
– Blepharitis
- lid hygiene, topical lubricants
– Dry Eye
- Topical lubricants (drops / gel + ointment at night)
– Conjunctivitis (Chlamydia – GUM)
• Refer to secondary care
– Corneal ulcer (?abrasion)
– Corneal problems in CL wearers
– Anterior uveitis (early treatment – quicker response…….topical steroids
……..recurrent AAU)
– Acute angle closure (ophthalmic emergency)
Some common conditions
The Red Eye
• <24 hrs to ARC
•
Ocular emergencies: C. ulcer, anterior uveitis, acute angle closure
• <72 hrs to ARC
•
“severely” symptomatic patient due to blepharitis / dry eye /
keratoconjunctivitis (?) / episcleritis / ?scleritis
• Referral via GOS 18 (soon appt)
•
Severe lid margin abnormalities (entropion with lashes rubbing the
cornea)
• Referral via GOS 18 (routine)
•
Relatively minor symptoms and signs
Some common conditions
• Watery eye
– GOS 18 referral (rarely needs anything other than
a routine appt)
– Examine
• lid margin (entropion / ectropion / blepharitis)
• Puncta (stenosis / apposition to globe)
• Tear film (meniscus / debris)
• Ocular surface (corneal PEEs)
Watery Eye
• Excessive tear production
– Any irritation to ocular surface
(ingrowing eyelash, blepharitis, “cold wind”, allergy)
– “Dry Eye”
• Problems with tear outflow
Watery Eye
• Excessive tear production
– Any irritation to ocular surface
(ingrowing eyelash, FB, “cold wind”, allergy)
– “Dry Eye”
• Problems with tear outflow
– Eyelid malposition (punctal eversion / stenosis,
ectropion)
– Blocked tear duct
Watery Eye
• When to refer
– Persistent, constant watering eyes
– Punctal stenosis, trichiasis
– minor op
– Punctal / lid malposition
– oculoplastic surgery
– Suspected blocked tear duct – oculoplastic surgery
• Treatable in primary care
– Dry eye , blepharitis
Watery Eye
• When
Dry
eye to refer
Blepharitis
Mild to moderate
Mild to moderate
Persistent,
• –topical
lubricantsconstant watering eyes
• Lid hygeine
• Drops / Gel / Ointment
• Topical lubricants
• Preservative-free drops
– Punctal stenosis, trichiasis – minor
op
Moderate to severe
Moderate to severe
• Punctal occlusion
• Oral doxycycline
Punctal
lid malposition
– oculoplastic
surgery
• –Refer
to eye /clinic
• Refer to eye
clinic
– Suspected blocked tear duct – oculoplastic surgery
• Treatable in primary care
– Dry eye , blepharitis
Watery Eye
• When to refer
– Persistent, constant watering eyes
– Punctal stenosis, trichiasis
– minor op
– Punctal / lid malposition
– oculoplastic surgery
– Suspected blocked tear duct – oculoplastic surgery
• Treatable in primary care
– Dry eye , blepharitis
• Managing patient expectations
Some common conditions
• Diabetic retinopathy
– All referrals to HES should ideally come via DESP
– If DR is noticed as part of routine ST:
• Check if pt already under DESP / HES (WMH / WEI)
• Referral needed / not??.....depends on multiple factors
• GOS 18 (routine / soon) to the patient’s local unit
– Vitreous Hge in a patient with DM
• Prev established PDR with PRP, no RD, ongoing FU
– Inform via urgent letter to the patient’s usual place of FU
• Not under care of ophthalmology service for DR
– Recent onset ….ARC (24 hr / 72 hr referral)
– Long duration….GOS 18 (soon)
Questions / Comments
Thank You