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Surgery 1 Attachment
2011/2012
SURGERY 1
CONTENTS
Any of the core clinical problems identified for Phase 3 may be seen on this attachment. It
provides a particular opportunity to focus on the following core clinical problems:
Introduction to Surgery 1 Block
2
Urology
Haematuria
Loin Pain
Swollen Scrotum
Urinary Symptoms
3
6
8
10
Otolaryngology (ENT)
Blocked Nose
Deafness
Hoarseness
Tinnitus
13
17
22
25
Ophthalmology
Foreign Body in Eye
Loss of Vision
Painful Red Eyes
Squint
29
34
39
43
Please see related documents below on Blackboard:
Relating the Curriculum Outcomes to the GMC Good Medical Practice
(2006)
Core Clinical Problems
Surgery 1 Attachment
2011/2012
Surgery 1
This attachment will include teaching in Urology, Ophthalmology and Otolaryngology. The
whole group will spend a week in Urology and then will proceed to spend one and a half
weeks in each of Ophthalmology and Otolaryngology.
Urology [Block Organiser: Mr D J Byrne]
Unless advised otherwise, all students allocated to Ninewells or Fife placements should
report to Clinical Skills, Ninewells Hospital at 9.00 am on the Monday morning. You will be
met by Dr. Lysa Owen/Mr. D Das Chaudhury or one of the urology members of staff who will
briefly outline the week and give you your timetable. After this session Fife students can
travel to their placement.
You will be advised to identify a patient on the urology Ward 33 to write up the history,
examination and brief discussion. Please read “Surgery 1 Urology Introduction and Self
Assessment” before you start the block (document found on Blackboard). Any difficulties or
queries you have with the self assessment questions can be addressed during the week.
You will be graded for the week on your patient’s case report.
Essential Urology is the recommended text for the Urology course (many copies are
available in the Ninewells Library and in the Medical Bookshop in Ninewells).
Ophthalmology [Block Organiser: Dr C J MacEwen]
Students should meet for the introduction to the course in the Demonstration Room, Ward
24/25, Ninewells Hospital, on the first day at 9 am.
This is a 7-day clinical course, the aims of which are to teach basic ophthalmic clinical skills,
including examination of the anterior segment of the eye, ophthalmoscopy, examination of
eye movements and visual fields. Clinical teaching in outpatients and wards will be
augmented with small group tutorials, video and slide presentations. The course is designed
to be as interactive as possible and is concluded with an assessment. Core knowledge as
essential to ophthalmology in general practice and as a PRHO is stressed.
The basic textbook recommended for the course is ABC of Eyes. Formative assessment at
the end of the course is based on attendance, a short MCQ paper, an OSCE and a case
report of an ophthalmic patient.
Please be aware that mydriatic drops will be used during the practical ophthalmoscopy
session Monday morning (Day 1). Therefore, all contact lenses must be removed prior to
arrival. Additionally, it is recommended not to drive until late afternoon.
Otolaryngology/Head and Neck Surgery [Block Organiser: Mr Stephen Jones]
The students assigned to Otolaryngology/Head and Neck Surgery should assemble in the
Demonstration Room on Ward 26 Ninewells Hospital at 9.30 am on the first Wednesday of
the rotation. Each student will be given an information pack, which contains a textbook and
a list of aims and objectives for the course in Otolaryngology/Head and Neck Surgery. The
student will follow a detailed timetable of tutorial sessions; work in the out-patient clinics,
wards and sessions in the operating theatres. During your 1½ week ENT rotation the
student will be required to write a two page report on a patient with one of the core problems
listed under special senses.
PLEASE NOTE THAT MR JONES IS NOW USING ONE OF THE DUNDEEMEDBLOGS
SITES TO SUPPORT THIS ENT BLOCK AND HAS PUT ALL THE CONTENT OF THE
STUDY GUIDE WITHIN THIS SITE – PLEASE GO TO
http://medblogs.dundee.ac.uk/ent for all information regarding the block, contacts any
assessment requirements and more.
© University of Dundee
Page 2
Medical School
Surgery 1 Attachment
2011/2012
Haematuria
A 68 year old man attends your GP surgery with a history of 24 hours frank haematuria four
days ago. It has cleared up completely and he feels he is wasting your time. What do you
tell him?
He then asks what are the possible causes for the blood in his urine. Can you summarize
the causes simply for him?
He agrees to co-operate with you. What points do you ask about specifically in the
history and what do you concentrate on during the physical examination?
What simple tests do you perform in the surgery?
What simple tests would you send to the hospital laboratory?
As his GP you refer him for further investigations at the local hospital. You are now the
doctor in the hospital and you have to tell him that he needs some tests to find out the cause
of his bleeding. He asks you what tests are required and what does each entail. How do
you respond?
At the end of the tests he is found to have a large solid mass on his right kidney. What is
the likely diagnosis in this case?
What is the mainstay of treatment for this?
© University of Dundee
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Surgery 1 Attachment
2011/2012
HAEMATURIA
A 68 year old man attends your GP surgery with a history of 24 hours frank haematuria four
days ago. It has cleared up completely and he feels he is wasting your time. What do you
tell him?
No. He’s not wasting your time. A tumour might only bleed once so a single episode
is significant
He then asks what are the possible causes for the blood in his urine. Can you summarize
the causes simply for him?
There are many causes for haematuria but in urology the big 4 are
TUMOURS STONES INFECTION TRAUMA
He agrees to co-operate with you. What points do you ask about specifically in the history
and what do you concentrate on during the physical examination?
Keeping the above 4 causes in mind ask about falls etc; dysuria, frequency, urgency,
loin pain, shivery, feeling fluey; severe loin to groin pain, past history of stones;
weight loss, anorexia, malaise etc
On examination check vital signs (pyrexia, tachycardia ?septic; hypertensive
?nephrological cause), look for loin tenderness or mass and suprapubic tenderness
or mass. In males a DRE to feel if prostate is malignant. Possible vaginal pelvic exam
in female
What simple tests do you perform in the surgery?
Urinalysis by dipstick: look for blood, leucocytes and nitrites (infection), lots of
protein (leaky glomeruli ?glomerulonephritis ??refer to nephrology)
What simple tests would you send to the hospital laboratory?
Send urine for microscopy (can see red blood cells, white blood cells and bacteria.
Staining can show malignant cells. Lots of crystals may suggest stones. Red cell
casts suggests leaky glomeruli). Check haemoglobin (had haematuria) and creatinine
(if hypertensive with lots of proteinuria and a raised creatinine ?nephrology referral
As his GP you refer him for further investigations at the local hospital. You are now the
doctor in the hospital and you have to tell him that he needs some tests to find out the cause
of his bleeding. He asks you what tests are required and what does each entail. How do
you respond?
A bladder inspection to look for bladder cancer usually transitional cell carcinoma). A
kidney scan to look for lumps on the kidney (either cysts or solid lumps – if solid it is
a renal cell carcinoma). An intravenous urogram to look for filling defects in the renal
pelvis and ureter indicating possible transitional cell tumours in these areas
At the end of the tests he is found to have a large solid mass on his right kidney. What is the
likely diagnosis in this case?
Renal cell carcinoma
What is the mainstay of treatment for this?
Nephrectomy
© University of Dundee
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Surgery 1 Attachment
2011/2012
Recommended Reading
To make the most of this section you should have to hand the following texts:-

Essential Surgery, Burkitt, Quick & Gatt, 2nd Ed., Churchill Livingstone
1996.

Essential Surgical Practice, Cuschieri, Giles & Moussa, 3rd Ed.,
Butterworth-Heinemann 1995.

Clinical Examination, Epstein, Perkin, de Bono & Cookson, Mosby 1992.
© University of Dundee
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Loin Pain
A 34 year old female presents with a 24 hour history of right loin pain. What information are
you particularly concerned about in the history?
What are the main points to concentrate on in the physical exam?
What is the first thing you would do with this patient?
As a GP what simple tests would you do?
Her pain does not settle and she is referred to the hospital. As the receiving doctor what
information do you need to have in order to assess the patient properly?
What definitive investigation would you order to try and diagnose this lady’s pain?
The outcome of the investigations shows she has an obstructed right kidney caused by a
5mm stone in the lower third of the ureter. How in general terms do you manage this lady
over the next 24 hours?
What are the indications for emergency treatment of this lady’s obstructed kidney?
What are the options to relieve the obstruction to this kidney, particularly in the emergency
situation?
What are the main methods of treating a ureteric stone?
If the patient at the beginning of this case was a 78 year old male with no history of urinary
stones, how would that have changed your thinking?
© University of Dundee
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Surgery 1 Attachment
2011/2012
LOIN PAIN
A 34 year old female presents with a 24 hour history of left loin pain. What information are
you particularly concerned about in the history?
You have been told the site and duration of the pain. Ask the rest of the pain questions ie
radiation, character, periodicity, aggravating and relieving factors and associated symptoms
(particularly lower urinary tract symptoms). Ask about past history (has she had it before?),
LMP, feeling feverish or fluey.
What are the main points to concentrate on in the physical exam?
Check Temp, Pulse, BP and RR. Look for tenderness in the loin and abdomen.
What is the first thing you would do with this patient?
Give pain relief. Usually a NSAID (eg diclofenac) or if this doesn’t help, an opiate
As a GP what simple tests would you do?
Urinalysis (blood would be expected if there is a ureteric stone; leucocytes and nitrites if UTIcould co-exist with stone. If leucocytes and/or nitrites are positive ?send urine for culture).
Check creatinine and WBC and a pregnancy test.
Her pain does not settle and she is referred to the hospital. As the receiving doctor what
information do you need to have in order to assess the patient properly?
What the GP found on examination. What tests the GP has done (with results, if available)
and what drugs the GP has administered
What definitive investigation would you order to try and diagnose this lady’s pain?
Non-contrast CT stone search OR intravenous urogram (IVU)
Advantages of IVU – gives good functional information and less radiation
Advantages of CT – no contrast means no risk of reaction and no need to gain iv
access. CT takes less time to perform. CT images 100% (nearly) of stones.
The outcome of the investigations shows she has an obstructed right kidney caused by a
5mm stone in the lower third of the ureter. How in general terms do you manage this lady
over the next 24 hours?
Analgesia and encourage oral fluids. She could be discharged and seen in the clinic in 1-2
weeks.
What are the indications for emergency treatment of this lady’s obstructed kidney?
1. An obstructed, infected kidney – If there is infection above an obstruction then
there is infection in an enclosed space. This is now by definition an abscess and
needs to be drained.
2. A single functioning kidney – This may be because the kidney was removed
previously (patient will tell you or there will be an abdominal scar) or the patient
may have been born with one kidney and if not discovered previously will be
picked up by a raised creatinine (should be normal with a unilateral ureteric stone
and two functioning kidneys) or absence on the IVU or CT.
What are the options to relieve the obstruction to this kidney, particularly in the emergency
situation?
This is best performed with a percutaneous nephrostomy done under local
anaesthetic in the x-ray department under ultrasound control. The other option is to
do a cystoscopy and place a JJ ureteric stent up to the kidney in a retrograde fashion.
What are the main methods of treating a ureteric stone?
Extracorporeal Shock Wave Lithotripsy (ESWL) OR in-situ lithotripsy via a
ureteroscope using a laser or ultrasonic stone disintegrator
If the patient at the beginning of this case was a 78 year old male with no history of urinary
stones, how would that have changed your thinking?
He may have a leaking Abdominal Aortic Aneurysm. Can present with symptoms very
like a left ureteric colic. Get an ultrasound. It is unusual to get your first urinary
stone after the age of 50 years.
© University of Dundee
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Scrotal Swelling
A 26 year old male presents with a 4 week history of a swelling in his right hemi-scrotum.
What questions do you ask him to try and clarify the nature of the swelling?
On clinical examination how do you tell a scrotal swelling arising from within the scrotum
from a swelling that has migrated into the scrotum from above?
What is the likely diagnosis if the swelling has migrated into the scrotum from above?
If you establish that the swelling arises from within the scrotum what two characteristics of
the swelling need to be established so as a clinical diagnosis of the swelling can be
made?
After you make a clinical diagnosis what special investigation would you order to
confirm this?
If the swelling is a solid testicular mass what is the likely diagnosis?
If this is confirmed by special investigation what blood tests would you order?
What is the first line treatment for this condition?
Is the outlook, in general, good or bad for this condition?
© University of Dundee
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SCROTAL SWELLINGS
A 26 year old male presents with a 4 week history of a swelling in his right hemi-scrotum.
What questions do you ask him to try and clarify the nature of the swelling?
Thinking of causes. Hydrocele (or haematocele), epididymal cyst, testicular tumour and
epididymitis. (Varicocele can sometimes be called a swelling by the patient, but not usually).
Relating questions to the causes: was there any pain, fever, fluey feeling, urethral discharge
(epididymitis), any history of trauma (haematocele), did the swelling increase in size over a
short period (?tumour). Also ask about undescended testis.
On clinical examination how do you tell a scrotal swelling arising from within the
scrotum from a swelling that has migrated into the scrotum from above?
You try to “get above the swelling”. That is, can you feel a normal spermatic cord above the
swelling or does the swelling disappear into the groin.
What is the likely diagnosis if the swelling has migrated into the scrotum from above?
An inguinal hernia.
If you establish that the swelling arises from within the scrotum what two characteristics of
the swelling need to be established so as a clinical diagnosis of the swelling can be made?
Is the swelling cystic or solid AND is it associated with the testicle or the epididymis?
Cystic/epididymis=epididymal cyst. Cystic/testicle=hydrocele
Solid/epididymis=epididymitis. Solid/testicle=testicular tumour
After you make a clinical diagnosis what special investigation would you order to confirm
this?
Scrotal ultrasound
If the swelling is a solid testicular mass what is the likely diagnosis?
As above
If this is confirmed by special investigation what blood tests would you order?
Testicular tumour markers ( -HCG, -fetoprotein)
What is the first line treatment for this condition?
Inguinal Orchidectomy/removal of testis
Is the outlook, in general, good or bad for this condition?
Good
© University of Dundee
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Urinary Symptoms
LOWER URINARY TRACT SYMPTOMS (LUTS)
A 72 year old man presents to you complaining of poor flow, frequency, and nocturia.
What other specific questions would you ask in the history?
What features do you concentrate on in the physical examination?
You tell him he needs certain tests to investigate his condition further. What tests do you
think he should have and why?
After appropriate tests a diagnosis of bladder outflow obstruction secondary to benign
prostatic enlargement is made. What are the possible treatment options in such a case?
In a man with similar symptoms and severe low back pain as well as a PSA of 1012
presented what would you be concerned about?
How would you confirm your suspicions?
What is the first line treatment option in a patient such as this?
© University of Dundee
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Surgery 1 Attachment
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LOWER URINARY TRACT SYMPTOMS (LUTS)
A 72 year old man presents to you complaining of poor flow, frequency, and nocturia.
What other specific questions would you ask in the history?
You have been given a few of the LUTS. Fill in the rest. I remember them as: obstructive
symptoms – poor flow, hesitancy and post-void dribbling. Irritative symptoms – frequency,
urgency, nocturia and urge incontinence. Other LUTS – haematuria, dysuria, incontinence
and feeling of incomplete bladder emptying. Ask how long he has had the symptoms and if
they are deteriorating. Ask how much bother his symptoms cause. Ask if he is worried
about prostate cancer and enquire about constipation and drugs he is on (constipation and
drugs with anticholinergic side effects eg antihistamines or antidepressants and alphaadrenergic side effects eg nasal decongestants can all aggravate LUTS.
What features do you concentrate on in the physical examination?
Has he got a palpable bladder? If so, and if he has no pain or discomfort associated
with it then he is in chronic urinary retention. It is important to diagnose this as if it is
left undiagnosed it can lead to renal failure.
Do a digital rectal examination. Does his prostate feel smooth and soft (benign) or is
it hard and irregular (malignant)? Don’t worry about size.
You tell him he needs certain tests to investigate his condition further. What tests do you
think he should have and why?
It is usual to measure a flow rate (basically how quickly he can pee, expressed in
mls/sec [normal approx 15mls/sec]). However this, in itself, does not determine
whether a patient should be treated or not. A flow rate is followed by a post-void
bladder residual volume measurement. This is important. If it is say 600mls then this
patient is in chronic retention and needs to be treated as such (catheterise). The
normal post-void residual is <50mls. Cystoscopy is not routine in the investigation of
LUTS. PSA might be done if the prostate feels malignant or the patient wants it done
after suitable counselling.
After appropriate tests a diagnosis of bladder outflow obstruction secondary to benign
prostatic enlargement is made. What are the possible treatment options in such a case?
Watchful waiting: If there is no concern about prostate cancer and if the bladder empties
well then the decision to treat is governed by the bother the LUTS cause the patient. If the
patient is happy with his symptoms then watchful waiting is appropriate.
Medical therapy: Alpha-blockers which relax the smooth muscle in the bladder neck,
prostate capsule and prostate stroma. The reduces the resistance against which the
patient has to pee. The effects are immediate and about 70% of patients get benefit.
Side effects include muzziness in the head, nasal congestion and rarely postural
hypotension. 5-alpha reductase inhibitors: These block the activation of testosterone
in the prostate and cause the prostate to shrink by about 20% in a year. Takes at least
3 months to kick in symptom-wise. Side effects include impotence, gynaecomastia
and reduced ejaculate volume.
Prostatectomy: Usually a Trans Urethral Prostatectomy but can be done as an open
operation through an abdominal incision. Both operations achieve the same thing. If
you imagine the prostate is an orange then both operations remove the fruit of the
orange and leave the skin (capsule) behind.
© University of Dundee
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In a man with similar symptoms and severe low back pain, anorexia, malaise and weight
loss as well as a PSA of 1012 presented what would you be concerned about?
Prostate cancer
How would you confirm your suspicions?
Do a prostate biopsy.
What is the first line treatment option in a patient such as this?
Deprive the tumour of testosterone. This can be achieved by doing a bilateral orchidectomy
(castration) or giving a LHRH analogue injection. This stops the pituitary secreting LH,
which in turn stops the testicle producing testosterone, which has the same effect as
castration. This treats all the symptoms and makes him feel better in a few weeks. About
80% of prostate cancer responds to this treatment. However after about 18 months the
tumour becomes hormone resistant and after that the symptoms he first presented with
return and further treatment is purely palliative eg TURP for bladder outflow obstructive
symptoms, local radiotherapy for localised pain from bony metastases, analgesia for more
diffuse pain etc.
© University of Dundee
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Blocked Nose
What is Stuffy Nose?
“Blocked nose” is one of the most common complaints for which patients seek advice in
general practice. Not all cases are due to “colds” or sinusitis: approximately 10% of the
population suffer from perennial allergic rhinitis making it the most common of the allergic
conditions. There are about half a dozen common conditions causing nasal blockage, all of
which are relatively straightforward to diagnose and rewarding to treat. The quality of life of
your patients will likely be enhanced if you can take a little time now to gain an
understanding of these common conditions which are responsible for quality of life
impairment amongst all age groups.
What Symptoms Do Patients Commonly Present With?
Primary
nasal obstruction
nasal stuffiness
rhinorrhoea
post nasal discharge (PND)
hyposmia/anosmia
facial discomfort/pain
sneezing
Secondary
snoring
dry mouth/throat
facial swelling
toothache
eye discomfort
headache
Think... What are Possible Aetiologies?
Common Conditions
Typical Symptoms
common cold
Hayfever
Perennial rhinitis
nasal polyps
septal deviation
adenoid hypertrophy
chronic rhinosinusitis
acute rhinosinusitis
Less Common Conditions
common cold symptoms
seasonal, sneezing, clear rhinorrhoea
all year, sneezing, clear rhinorrhoea
mucoid discharge, hyposmia
often history of trauma, unilateral symptoms
young children, snoring, mouth-breathing
facial pain, purulent discharge
fever, facial pain, purulent discharge
Typical Symptoms
nasal foreign body
septal haematoma
congenital unilateral choanal atresia
septal abscess
benign and intermediate nasal neoplasia
malignant neoplasms
unilateral symptoms and discharge
history of recent trauma
unilateral symptoms in childhood
history of trauma & pain & fever
unilateral symptoms
pain & unilateral symptoms
© University of Dundee
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Discharge
Sneezing
Hyposmia
Pain
Common cold
Mucopurulent
yes
transient
discomfort
Post Nasal
Drip
transient
Hayfever
Clear
marked
transient
unusual
transient
clear if present
yes
mild
discomfort
yes
Purulent
mild
mild
marked
purulent
Mucoid
yes
marked
no
marked
None
none
mild
discomfort
mild
Perennial
rhinitis
Acute
Sinusitis
Nasal polyps
Septal
Deviation
What are Important/Relevant Questions to Ask on History Taking?
Laterality i.e. Bilateral or unilateral? This is an important question as the common benign
processes such as hayfever, nasal polyps and the common cold, cause bilateral symptoms,
whereas the less common but more serious conditions such as neoplasms or foreign bodies
will cause unilateral nasal obstruction and discharge etc. Note though that a nasal septal
deviation following trauma is an exception to this rule. Patients often complain about
alternating nasal obstruction. Generally one side of the nose will be blocked at any time and
this will change to the other side after a few hours. This is called the nasal cycle and is
normal. Patients with rhinitis often notice this more than others. Those with a nasal septal
deviation may have unilateral obstruction with intermittent patency on the unaffected side.
Periodicity? Continuous or seasonal? For example, hayfever strikes mainly in the spring and
summer, whereas allergic rhinitis due to house dust mite will give symptoms all year round,
aggravated by dust exposure. The nasal stuffiness associated with nasal polyps and
adenoid hypertrophy is continuous.
Severity? Given the marked individual variation in the degree to which patients will rate nasal
stuffiness as a problem this is often difficult to quantify. It is important to gain some idea of
the extent of quality of life impairment. For example, does the patient classify the blockage
as mild, moderate or severe? Bear in mind that mild obstruction for a professional wine
taster may cause more quality of life impairment than severe obstruction in a sewerage
worker.
Associated symptoms? Especially rhinorrhoea and the nature of any discharge. In allergic
rhinitis the discharge is clear and often watery, the discharge associated with nasal polyps is
often thicker, whereas the discharge associated with an infective process such as
rhinosinusitis or a foreign body will invariably be purulent. Associated hyposmia is common
and may be severe in conditions such as nasal polyposis. Facial pain is a common feature of
sinusitis, but mild generalised pains and discomfort can be seen with perennial rhinitis and
hayfever. Post-nasal discharge is frequently complained of by patients who often describe it
as catarrh, it is generally not a sensitive symptom unless the discharge overtly purulent. It is
very common in smokers.
Associated conditions? Note that allergic rhinitis and sinonasal polyposis are more common
in asthmatics. Conditions such as pregnancy and passive smoking can trigger vasomotor
rhinitis, while a history of trauma to the nose may raise suspicion of a septal dislocation or
haematoma.
Potential aetiological factors should be enquired about. This calls for some detective work,
investigating the patients home and occupational lifestyle looking for possible environmental
aetiological factors. Examples include allergies to animal dander such as dog or cat hair.
© University of Dundee
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What is an Appropriate Clinical Examination and What Common Investigations are
Currently Used?
Nasal stuffiness is one of the more common symptoms complained of by patients attending
their primary care physician. These patients will be seen frequently during your General
Practice rotation. This would be an ideal time to practise your history taking and examination
skills.
In Primary Care rhinoscopy is best performed using the auroscope as a “rhinoscope”. The
following should be noted: position of septum; nature of turbinate mucosa; presence of any
abnormal discharge; presence of polyps or any other abnormal swellings. It is important to
examine the pharynx (for post nasal discharge, mucosal desiccation, granular pharyngitis)
and the face and eyes (for associated conjunctivitis, any facial swelling or tenderness) as
well. Take the opportunity to develop these skills during your Phase 3 block.
Investigations
Investigations are not usually necessary in the diagnosis of stuffy nose, and most conditions
can be diagnosed on the clinical features alone. The importance of careful history taking
cannot be over emphasised. Tests in common use include:

RAST and skin prick tests for allergies.

The paranasal sinuses are best imaged by CT scan. In many radiology
departments plain X-Rays of the paranasal sinuses are no longer carried
out.
Also:


Nasoendoscopy with or without biopsy (by an ENT surgeon)

Rhinomanometry - an objective test of nasal airway volume which may be
useful in a limited number of patients

Tests of olfaction - again not often used in routine practice
Sinus endoscopy and middle meatal aspirate for culture (by an ENT
surgeon)
What Should I Do?
By the end of Phase 3 you should be able to:

Take an adequate history to diagnose the common causes of stuffy nose


Be proficient at external examination of the nose and rhinoscopy

Manage the common conditions causing stuffy nose including: hayfever, the
common cold, perennial allergic rhinitis, vasomotor rhinitis, nasal polyposis,
sinusitis and nasal trauma

Communicate with the relevant specialist and allied members of the medical
team knowing which conditions should be referred and when

Give lifestyle advice in relation to recovery periods for the infective and
traumatic conditions causing “stuffy nose”, and be able to give prognostic
advice for the chronic conditions such as allergic rhinitis

Prioritise urgency of referral, for patients with conditions such as septal
haematoma, nasal foreign body, complications of sinusitis such as orbital
cellulitis or possible malignancy.
Assemble a full differential differential diagnosis of nasal obstruction and
discuss further investigations required if appropriate
© University of Dundee
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Where Can I Learn About Stuffy Nose?

During your ENT attachment you will be exposed to patients with “stuffy
nose” referred to the ENT out-patient clinic. Try to see some live nasal
surgery during your ENT theatre attachment and meet some of the ENT inpatients having surgery for nasal obstruction, e.g. septoplasty, or nasal
polyp surgery.

During your General Practice attachment, patients with nasal complaints will
be abundant, take the opportunity to test out your nasal-diagnostic skills.
© University of Dundee
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Problem as seen by the Doctor
Blocked Nose
Problem as experienced by your patient
______________________
System links
Special Senses - ENT
What a doctor will be able to do:
1
2
3
4
What were the relevant positive and negative findings on clerking your patient?

RAST.

Allergy skin testing.

What investigations helped to establish your patient’s problem?
5
How can you manage the following:

perennial allergic rhinitis

nasal polyps

nasal trauma

sinusitis
What advice if appropriate, did your patient receive to prevent recurrence?
6
What were the main concerns of your patient and how did you deal with them?
7
What is the evidence underpinning the current treatment of perennial allergic
rhinitis?
How a doctor approaches their practice:
8
Can you link the common clinical presentations to the underlying causes?
9
What are the age specific issues in relation to this problem?
10
What factors help to determine a differential diagnosis for your patient?
Doctor as a professional:
11
12
What are the current guidelines concerning the role of the pharmacist in the
care of patients with a blocked nose?
Why is it important to refer the following urgently:

septal haematoma

orbital cellulitis
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Deafness
What is Hearing Loss in Adults?
There are many causes of hearing loss in adults some of which are discussed below. The
onset can be sudden, or gradual with progression and the process can be unilateral or more
commonly bilateral. The degree of hearing loss can vary from minor with little handicap to
complete loss of hearing with severe problems as a consequence.
What are the causes of hearing loss in children?

4% school children have conductive deafness - most commonly due to glue
ear

0.3% school age children have sensorineural deafness - associated with
genetic causes, prematurity, birth asphyxia, severe hyperbilirubinaemia
Both are associated with delayed speech development
Why is Hearing Loss Important?

Only fifteen medical conditions account for 25% of all referrals to hospital
outpatient clinics. Of the top five, “Hearing Problems” is the second most
common after joint pain and ahead of abdominal pain, breast lumps and
back pain. In the UK 80% of 80 year olds have a hearing loss and 2/3 of this
age group have some hearing handicap.

It may be a sign of serious illness requiring medical intervention; for
example some people with untreated non-insulin dependant diabetes
mellitus present with hearing loss.

Hearing loss might be a sign of life threatening disease, such as
nasopharyngeal carcinoma or polyarteritis nodosa, requiring urgent
treatment.
Some Causes of Hearing Loss
Notes

Sudden sensorineural hearing loss is a medical emergency. Patient should
be seen within 24 hours of the onset if any possible treatment is going to
succeed.

Unilateral hearing loss needs investigation to exclude serious illnesses such
as nasopharyngeal cancer (if conductive) and schwannoma of the eighth
nerve (if sensorineural).
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Inherited
Cause
Autosomal Dominant
Autosomal Recessive
X-Linked
Example
Otosclerosis
Comments
Treat with Fluoride, Stapedectomy
or hearing aid
Familial Hearing loss in old age
Mid Frequency Sensory Loss
This is rare
Acquired
Cause
Infection
i) Bacterial
ii) Viral
Example
Comments
Acute Otitis Media
Meningitis
Post-Viral
1% suffer hearing loss
Commonest after Mumps; usually
unilateral
Ramsay-Hunt Syndrome in Herpes
Zoster
Still occurs occasionally
Is one cause of Otitis Externa
Specific
iii) Other
Trauma
Neoplasia
Treponema pallidum
Fungal
Chronic Suppurative
Media
Direct
Blast Injury
Noise
Barotrauma
Inner Ear
Middle Ear
Otitis
Outer Ear
Eighth Cranial nerve
Intra Cranial
Post Nasal Space
Iatrogenic
Surgical
Pharmaceutical
Metabolic
Vascular
Miscellaneous
© University of Dundee
Hyperlipidaemia
Diabetes
Paget’s Disease
Cotton bud, hair grip etc.
Explosion
Occupational and recreational
Divers and fliers
Primary tumour is unknown
Rare and poor prognosis as late
presentation
Rare
Must be excluded in unilateral hearing
loss
Must be excluded in unilateral hearing
loss
Can present with unilateral conductive
loss
Hearing loss can occur during any
anaesthetic and is not just a
complication of ear surgery
eg Cisplatinum, Aminoglycosides, Loop
Diuretics, NSAID
Can cause compression of the eighth
nerve as it passes through the skull
Vasculitis
Vasculopathy
Meniere’s disease
See Dizziness
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Recommended Reading


This can be obtained from your standard textbooks;


The Scottish Council on Deafness (http://www.scod.org.uk/)
Further information, books and leaflets are available in the Department
library, the Ninewells library and the Audiology Department (from Mrs
Peacock).
The Royal National Institute for the Deaf (http://www.rnid.org.uk)
What Should I Do?
By the end of Phase 3 you should be able to:


Take a history:
 This is always an important part of the differential diagnosis. It should include an
assessment of the patient’s hearing handicap so that a proper rehabilitation
programme can be planned.
Perform an examination and investigations:
 This examination depends on the potential diagnoses suggested by the history
but should include at least otoscopy and an assessment of vision and
manipulation skills (as part of any hearing aid assessment). Further medical and
neurological examination may be necessary.
Investigation will also depend on history and results of examination but should include at
least a pure tone audiogram. Further tests may be needed to define the site and nature of
the lesion causing the hearing loss or to assess any problems that are likely to be met during
hearing aid fitting. (Remember that there are other assistive listening devices as well as
hearing aids). Look at http://www.sarabec.co.uk for examples.).
Where Can I Learn About Going Deaf?

You will have opportunities to study hearing loss during your clinical
attachments in Otolaryngology. In addition, you will meet many people with
hearing problems during attachments in Medicine for the Elderly, General
Practice, Neurology and Speech and Language Therapy.

During your Otolaryngology attachment you should take the opportunity to
learn how to perform hearing tests. If you get the opportunity to perform an
audiogram yourself you could include this in your portfolio.
How do the Curriculum Themes Contribute?
Acute Care - Sudden sensorineural hearing loss is an emergency. The complications of
acute infection can be rapidly lethal.
Anatomy - Knowledge of the neural pathways associated with hearing loss is essential to
understand lesions of the eighth nerve, brain stem and auditory cortex.
Biochemical Medicine - Metabolic problems such as diabetes, hypothyroidism and
hyperlipideamia have far reaching effects and are not confined to the ear.
Behaviour - Hearing loss can lead to social isolation, frustration and depression.
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Child Health - Paediatric hearing loss is not covered in this study guide but is an important
topic in its own right.
Clinical Methods - As patients with a variety of clinical conditions present with hearing loss
these is scope to practice a wide range of clinical skills.
Community - Many hearing impaired people are based in the community and with direct
access clinics for hearing aids may never see a hospital practitioner. Community based
Social Workers and Occupational Therapists have a large role to play.
Computers and Information - Development of databases is needed to elucidate the
“idiopathic” causes of hearing loss.
Genetics - Inherited hearing loss can be passed on to the patient’s children.
counselling may be needed.
Genetic
Health Promotion and Disease Prevention - Boilermaker’s deafness was the first
occupational disease recognised for pension purposes. There is still a lot of scope for public
awareness raising exercises in the prevention of hearing loss.
Infectious Diseases - Still a significant cause of middle and external ear problems as well as
permanent hearing problems.
Investigative Procedures - Range from blood test to MRI depending on the diagnosis.
Medical Ethics - There are health economics issues. In a Health Service with a finite budget
should we spend money saving life or improving the quality of life or both.
Microbiology - The development of drug resistant organisms is one issue.
Oncology - Nasopharyngeal cancer, acoustic neurinoma and cerebello-pontine angle
tumours are the main concerns in this topic.
Physiology - The physiology of hearing is very complex and is probably outwith the scope of
an undergraduate curriculum.
Research Methods, Scientific Thinking & Statistics - There is scope for a wide range of basic
research from aetiology through to pathogenesis.
Surgery - External and middle ear problems may be amenable to surgery but most causes of
hearing loss in adults are sensorineural and so are not.
Disability & Rehabiltiation - This is the main topic with sensori-neural hearing loss. There is
a wide range of technical aids available in the rehabilitation.
Therapeutics/Pharmacology - Most patients with hearing loss are not amenable to
pharmaceutical therapy but you should be aware of drugs as a potential cause of hearing
loss.
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Problem as seen by the Doctor
Deafness
Problem as experienced by your patient
______________________
Special Senses – ENT/Neurology
System Links
What a doctor will be able to do:
1
2
3
What were your relevant findings from the history and examination of your
patient?

Perform hearing test

Interpretation of an audiogram

Assessment of manipulation skills

Assessment of vision
How did you investigate your patient’s deafness?
4
5
What are the common technical aids used in rehabilitation of the deaf?

What is the incidence of deafness in the UK community?

What measures would help to minimise the incidence?
Discuss in your tutorial.
6
What are the major circumstances of communication difficulties for deaf
patients and how does this impact on their lifestyle
7
How were your patient’s notes handled and what was recorded in them? Were
you aware of any auditing of records during this attachment?
How a doctor approaches their practice:
8
How can you relate the neural pathways to the following:


9
10
sensorineural deafness
conductive deafness
How did you cope with your own communication difficulties when seeing your
patient?
How did the findings from your patient help you to draw up a differential
diagnosis
Doctor as a professional:
11
What is the role of the following personnel in the care of a deaf patient:



12
Audiologist
ENT consultant
speech therapist
Which members of the health care team were involved in your patient’s care
and how was this planned? Did you attend any meetings?
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Hoarseness
What is Hoarseness?
Hoarseness or dysphonia is the term used to describe change in voice quality.
Why is Hoarseness Important?
All patients with hoarseness persisting for four weeks should have their larynges examined.
Persistent hoarseness may be caused by an organic lesion in the larynx or by damage to
one of the recurrent laryngeal nerves. Only a minority of cases will have laryngeal
malignancy; for example, a general practitioner in Tayside will see a new case of laryngeal
cancer once in 17 years on average. If this is diagnosed and treated early the prognosis is
excellent. The prognosis is poor if treatment is delayed. Other causes of hoarseness include
poor vocal technique and vocal abuse (for example in singers and teachers),
hypothyroidism, nasal and sinus disease and reflux oesophagitis.
What Should I Have Learned in Phase 1 and 2?




Basic anatomy of the larynx and vocal cords including innervation of the
cords.
Patient 4 in your phase 2 study guide, William MacKay
The station on “The Voice” in the integrated teaching area in phase 2 (also
available on Blackboard)
There is a video on examination of the oral cavity and larynx available in the
integrated teaching area and on Blackboard.
How Much Do You Remember From Phase 2? (Answers at end of study guide)
Why may intrathoracic malignancy cause hoarseness?
Damage to which recurrent laryngeal nerve most often causes hoarseness?
Recommended Reading

This can be obtained from your standard textbooks
What Should I Do?
By the end of phase 3 you should be able to







Take a history from a patient with hoarseness
Identify those cases of hoarseness which require laryngeal examination
Palpate the neck of patients with hoarseness for enlarged nodes.
To examine the oral cavity for ulcerating lesions
Investigate hoarse patients with a chest x-ray and a TSH (thyroid stimulating
hormone) investigation without delaying referral
Consider infective conditions such as croup and epiglottitis
Prioritise the referral of hoarse patients. Those patients with more severe
symptom such as stridor may require emergency referral by telephone.
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Where Can I Learn About Hoarseness?
You may see patients with hoarseness at:



The ENT out-patient clinic


The radiotherapy ward or combined radiotherapy/ENT outpatient clinic.
The Endocrinology clinic
The Respiratory Medicine clinic (remember that patients with
hypothyroidism and respiratory disease especially smokers, may also have
laryngeal cancer)
Paediatric ward
How Do the Curriculum Themes Contribute?
Pathology/Oncology - 99% of laryngeal cancer is squamous cell carcinoma.
Disability and Rehabilitation - Speech and Language Therapists have a major part to play in
the rehabilitation of patients with pharyngeal and laryngeal problems. They take a holistic
approach to patient care designing a rehabilitation programme involving lifestyle and
psychological aspects as well as physical management.
Health Promotion - Many of the causes of hoarseness relate to lifestyle particularly cigarette
smoking and alcohol. This is a good opportunity to think further about health promotion and
disease prevention and patient information to help stop smoking.
Answers


Through involvement of the recurrent laryngeal nerve.
The left.
It passes the left hilum and may be involved in hilar
lymphadenopathy/malignancy.
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Problem as seen by the Doctor
Hoarseness
Problem as experienced by your patient
System Links
______________________
Special Senses – ENT/Respiratory/Endocrine
What a doctor will be able to do:
1
What were your findings on palpation of the neck nodes? What were the other
relevant findings in your patient?
2
3
How would you investigate a patient with hoarseness which has lasted for:

one week,

three weeks?
4
5
What measures can be taken to reduce the incidence of hoarseness in the
population?
6
What were the important findings to record in the notes? Why are notes taken
and recorded?
How did information technology contribute to the overall care of your patient?
7
How a doctor approaches their practice:
8
From your knowledge of anatomy explain how hoarseness can arise.
9
How would assess you own competence in dealing with your patient?
10
How do you distinguish hoarseness from functional dysphonia?
Doctor as a professional:
11
12
What is the role of the speech therapist in the rehabilitation of patients with:

poor vocal technique?

following laryngectomy?
Why is it important to prioritise the referral of patients with hoarseness?
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Tinnitus
What is Tinnitus
Tinnitus is the sensation of sound heard in the ear(s) when there is no external sound
source. The noise is probably generated by damaged hair cells within the cochlea and is not
an hallucination. The noise can be unilateral or bilateral, continuous or intermittent, or
pulsatile or non-pulsatile. If the noise can be heard by other people it is said to be objective.
The noise can be described in a variety of ways including:- ringing, water running, hissing,
machine noise, whining or humming.
Why is Tinnitus Important?

It is very common, although, it does not cause distress in all of those who
hear it. When it does cause problems these can severely affect the quality of
life of the patient. If this is the case, early and correct management is
essential for a successful outcome as, once established, tinnitus is usually
permanent.

It may be a sign of serious illness requiring medical intervention; for
example, some people with cerebellar diseases present with clicking tinnitus
secondary to palatal myoclonus and carotid artery stenosis can give
pulsatile tinnitus. vestibular schwannomas and cerebello-pontine angle
tumours can cause unilateral tinnitus.

Tinnitus is a common side effect of some drugs including NSAIDs.
Some Causes of Tinnitus
Tinnitus can be caused by any process affecting the auditory pathway at any point from the
pinna to the auditory cortex. In most patients the tinnitus is associated with a hearing loss.
Patients may feel that they have difficulty in hearing because the noise of the tinnitus. In
reality if they did not have a hearing loss they would not have the tinnitus. Sometimes
improvement in the hearing may cause resolution of the tinnitus.
Pulsatile tinnitus, in time with the heartbeat, may be caused by a vascular flow problem. This
can be transmitted from the carotid artery in stenotic disease. It can also be due to vascular
tumours such as jugular bulb tumour (glomus jugulare), intra-cranial arterio-venous
malformations and abnormal vessels in the middle ear. The pulsatile nature of the symptom
is important, and its timing with respect the the patient’s pulse.
The short lived noise that most people hear sometimes is normal. Some people become
aware of other normal noises such as the Eustachian tube opening during swallowing, the
noise that eating apples or crisps makes, breathing etc. The human ear is so sensitive to
sound that sound pressure so low that the ear drum is only moved by one Angstrom unit can
be heard. It is surprising that we do not complain of bodily noises more often.
Recommended Reading


This can be obtained from your standard textbook.
The Royal National Institute for the Deaf (http://www.rnid.org.uk) and The
British Tinnitus Association (http://www.tinnitus.org.uk) are useful sources of
further information
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What Should I Do?
By the end of Phase 3 you should be able to:
 Take a history
 This is always an important part of the differential diagnosis. It is also important to
define exactly what problems the patient has secondary to the tinnitus so that a proper
management programme can be planned.
 Perform an examination and investigations:
 The examination depends on the potential diagnoses suggested by the history but
should include at least otoscopy. Further examination of general medical systems and
neurology may be necessary.
 Investigation will also depend on history and results of examination but should include
at least a pure tone audiogram. Further tests may be needed to define the site and
nature of the lesion causing the tinnitus.
 Consider management options in tinnitus:

Hearing aids are an integral part of the management in those patients with hearing
problems and solving their auditory difficulties may be all that is needed.
 The response to any chronic repetitive stimulus whether it is a fan, a fridge or tinnitus is
the same. Three stages have to be gone through:
 Awareness. “I can hear a noise”
 Orientation. “What is the noise? Can I safely ignore it”?
 Habituation. “It is only the clock ticking I can safely ignore that”.
Note that the clock does not stop ticking. You are just no longer aware of its tick. If you
want to check that it has not stopped you can choose to attend to the clock and hear the tick
again. Patients present because they are aware of the noise but do not know what it is or
whether it is safe to ignore. If the doctor can explain why the noise is there and that
although it will not go away it is safe to ignore the noise then most patients can learn to live
with their tinnitus.
You have not taken the tinnitus away but just as with the clock ticking patients can, with help,
choose not to attend. The aim is to alter complaint behaviour. The patient comes and asks
you to take the noise away so that they will feel better whereas you are telling the patient
that they will feel better if they accept that the noise is permanent. This can be a difficult
concept for patients and they may need considerable help, reassurance and counselling.
Over 80% of patients with tinnitus learn to cope with their noise successfully.
 Appreciate the role of clinical psychology for patients with tinnitus:

Patients who cannot habituate, or those who have habituated but decompensate after
bereavement for example, will require help from the clinical psychology service. The
psychologists offer a variety of skills including anxiety and stress management,
relaxation training, bereavement counselling, management of disordered sleep pattern
and cognitive behavioural therapy.
 Understand tinnitus maskers:
 These are white noise generators. The idea is that the masker noise replaces the
tinnitus. The patient can still hear a noise but it is meant to be more pleasant than their
tinnitus. Large comparative studies have shown that maskers do not provide any
additional benefit to counselling and hearing aids. However, a minority of patients really
like them and in those people they are of benefit.
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The other use of maskers is in Tinnitus Retraining Therapy. This involves the usual
reassurance, hearing aids and counselling but uses the maskers to retrain the brain to
become used to a continuous sound. The masker is used continuously for six hours per day
at first at a level just below that which completely drowns out the patients own noise.
The patient should just be able to hear the tinnitus as well as the masker, the loudness and
duration of use are then gradually reduced to nothing.
Where Can I Learn About Tinnitus?
You will have opportunities to study tinnitus during your clinical attachments in
Otolaryngology. In addition you will meet many people with tinnitus during attachments in
Medicine for the Elderly and General Practice.
How Do the Curriculum Themes Contribute?
Anatomy - Knowledge of the neural pathways associated with tinnitus is essential to
understand lesions of the eighth nerve, brain stem and auditory cortex.
Behaviour - Much of the management of tinnitus is based on explanation, reassurance,
anxiety and stress control, counselling and clinical psychology.
Biochemical Medicine - Metabolic problems such as diabetes, hypothyroidism and
hyperlipideamia can cause tinnitus and have far reaching effects outwith the ear.
Child Health - Tinnitus is not common in children and where it does occur usually causes no
disturbance.
Clinical Methods - As patients with a variety of clinical conditions present with tinnitus there
is scope to practice a wide range of clinical skills.
Health Promotion and Disease Prevention - Boilermaker’s deafness was the first
occupational disease recognised for pension purposes. Tinnitus can be a feature of noise
induced hearing loss and compensation claims. There is still a lot of scope for public
awareness raising exercises in the prevention of hearing loss and secondary tinnitus.
Infectious Diseases - Still a significant cause of middle and external ear problems which may
be associated with tinnitus.
Investigative Procedures - Range from blood test to MRI depending on the diagnosis.
Medical Ethics - There are health economics issues. In a Health Service with a finite budget
should we spend money saving life or improving the quality of life or both.
Oncology - Nasopharyngeal cancer, acoustic neuroma (vestibular schwannoma) and other
cerebello-pontine angle tumours are the main concerns.
Physiology - The physiology of hearing is very complicated, but a knowledge of the basics is
required.
Research Methods, Scientific Thinking, Statistics - There is scope for a wide range of basic
research from aetiology through to pathogenesis. No one has found a way to eradicate
tinnitus yet.
Surgery - External and middle ear problems may be amenable to surgery but this often has
no effect on tinnitus.
Disability & Rehabilitation - As there is no curative therapy available rehabilitation is the
management option of choice.
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Therapeutics/Pharmacology - No drugs have been found to remove tinnitus noises but the
symptom may be a drug side effect.
Problem as seen by the Doctor
Tinnitus
Problem as experienced by your patient
_______________________
Special Senses – ENT/Neurology
System links
What a doctor will be able to do:
1
2
3
4
5
6
What relevant history and examination was carried out in your patient?

Otoscopy.

Observe a pure tone audiogram.
How was your patient with tinnitus managed?
What measures can patients do for themselves to prevent damage to their
hearing?
How did your patient describe their tinnitus?
What additional information can you obtain from the suggested internet
resources?
How a doctor approaches their practice:
7
How does tinnitus arise?
8
What are the economic sequelae for both patient and society for someone
disabled by tinnitus?
Is there a reason why the tinnitus is causing distress at this time?
9
Doctor as a professional:
10
What is the role of the clinical psychologist in the management of tinnitus?
11
What would make you refer patients to

Neuro-otologist / Neurosurgeon?

Clinical psychologist?
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Foreign Body in Eye
Why are Foreign Bodies Important?
Injury to the eye by a foreign body is a very common clinical problem encountered by all
practitioners, particularly those working in general practice, accident and emergency and as
ophthalmic surgeons.
Many cause only transient discomfort and injury if managed correctly. These can be readily
treated. Others may be serious and sight-threatening.
It is therefore important that all doctors have a firm grasp of how to identify and manage
foreign bodies proficiently.
Types of Foreign Body Injury
Various classifications may be employed:
Mode Of Injury: (How did it get there? Is it likely to be serious?)

Low velocity.



High velocity.
Thermal.
Chemical.
Type of Material: (What is it made of? Which types are more worrying?)Eg

Dust.




Metallic.
Glass.
Organic.
Chemical.
Site: (Anatomical location).

Conjunctival.





Subconjunctival.
Subtarsal.
Corneal.
Intraocular.
Intraorbital.
Practical Considerations
History: How did it get there? What is it made of? This is the key to the problem.
The type of injury is important eg: Low velocity injuries are unlikely to have caused a penetrating injury.

High velocity injuries must be treated with a high index of suspicion for penetration.

Thermal injuries may cause severe ocular damage, usually refer to Ophthalmologist.

Chemical injuries are potentially extremely dangerous, know how to treat as an
emergency, must see an Ophthalmologist.
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Common Examples:
Low Velocity
Blown by the wind
While riding a bicycle etc.
Grinding
Drilling (rotary drill)
High Velocity
Hammering
Chiselling
Thermal
Hot / Molten metal
Liquids
Chemical
Alkali - lime, cement
Acid – battery
Examination: “I can’t see the eye because the patient won’t let me” !
This is a common problem/complaint. In most instances, unless there is a very high
suspicion of penetration, very adequate examination can be facilitated by pain relief via the
instillation of a local anaesthetic drop such as benoxinate, lignocaine amethocaine or
proxymetacaine.


Use a Bright Light and Magnification or Slit Lamp if Available.
Remember foreign bodies (F.Bs) are often small but cause intense pain or
irritation especially if on the cornea or sub tarsal area.
Specifically Examine:
Visual acuity
Subtarsal conjunctiva (evert upper lid)
Cornea
Conjunctiva including the lower fornix
Instil fluorescein to show any abrasions or scratches
Look at the pupil shape
Look for a hyphaema (blood in the anterior chamber)
Special Considerations
Subtarsal foreign bodies
Material often becomes trapped under the upper lid (in the subtarsal sulcus - approx. 2mm
from lid margin), and therefore does not spontaneously dislodge
Clues:
History of F.B. entry, F.B. sensation but no visible F.B.
Action:
Instil fluorescein look for linear abrasions on the cornea, usually superiorly
Evert upper lid
Penetrating injury
These are serious, sight-threatening injuries which must not be missed.
Clues:
History of high velocity F.B. injury
Distorted pupil
Hyphaema
Action:
Refer to an Ophthalmologist
Protect the eye
X-Ray orbits if time permits – do not MRI
Children - May be very difficult to examine and unless F.B. is very obvious. Should be
referred to an Ophthalmologist. May then even require examination under anaesthetic.
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Type of Material
You should be aware of problems which may be associated with certain types of foreign
bodies, for example:Infection
Although all FBs carry a risk of infection, organic FBs (eg plant material in agricultural
injuries) are of special note. Some of the latter may cause fungal infection.
Metallic Foreign bodies
If lodged in the cornea, these are frequently associated with a rust ring.
This should be removed to avoid permanent corneal staining.
If necessary refer to an ophthalmologist.
Metallic foreign bodies are more likely to cause ocular penetration.
Chemical Injuries
Although not usually classed as a foreign body injury, you should know about these.
They are sight-threatening emergencies.
Alkali injuries are particularly dangerous.
Treatment begins with immediate and copious irrigation until pH is neutral and then refer to
an Ophthalmologist. You should learn this topic in more detail.
How To Remove A Foreign Body
Simple foreign bodies are usually easy to remove.




Instil local anaesthetic drops.

Instil antibiotic e.g Chloramphenicol. Topical non steroidal anti sp inflammatories help
to relieve pain.

Pad eye for 24hrs, if patient prefers. Not mandatory.
Loosely adherent FBs may be removed using a wet cotton bud.
Others may require careful use of a green needle under magnification.
Corneal Metallic foreign bodies often have an associated rust ring, this should be
removed. If not easily achieved refer to an Ophthalmologist (who may use a rotary
burr).
What Should I Do?





Know high and low risk foreign body injuries including chemical injuries.
Know how to examine for foreign bodies in the eye and ocular adnexae.
Know how to remove superficial and sub tarsal foreign bodies.
Know the history and signs which suggest ocular penetration.
Know what to refer to the Ophthalmology Department.
Where Can I Learn More About Foreign Bodies In The Eye?
During your ophthalmology attachment take the opportunity to attend the treatment room
and find out if any foreign body injuries are expected, see for yourself how they are
managed. While attending Accident and Emergency sessions make an effort to find any
such patients.
How Do The Curriculum Themes Contribute?
A sound knowledge of basic eye anatomy is essential to allow logical assessment,
description and understanding of foreign body injuries. Revision of this is strongly advised to
facilitate study of ocular disease.
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Recommended Reading

ABC of Eyes. 2nd Ed.Elkington A.R., Khaw P.T. British Medical Journal
Publishing, ISN 0 7279 0766

Surgery 2 Opthalmology Section 3. Dent J A, Churchill Livingstone 2007
(3rd edition)
Further Reading

Clinical Ophthalmology. 3rd Ed. Kanski J.J. Butterworths. London, Boston,
Singapore.

Immediate Eye Care. Ragge N.K., Easty
London.

The Wills Eye Manual. Office and Emergency Room Diagnosis and
Treatment of Eye Disease. 2nd Ed. Cullom R.D. Jr., Chang B. J.B.Eds.
Lippincott. Philadelphia.
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Problem as seen by the Doctor
Foreign Body in Eye
Problem as experienced by your patient
_______________________
System links
Special Senses - Eyes
What a doctor will be able to do:
1
What features need to be obtained from the history? What specifically must be
examined in the eye?
2
Slit lamp examination.
Application of local anaesthetic drops and or fluorescein.
3
How would you investigate a patient who had been hammering and felt a foreign
body enter the eye.
4
What are the steps to be taken in removing a foreign body from the eye with
minimal damage?
How can the following be prevented:

Corneal foreign body from grinding

Chemical injuries
What would you do if the patient will not open his eye sufficiently for you to
conduct an adequate examination?
5
6
7
What current articles consider the management of foreign bodies in the eye – use
Medline to conduct a search?
How a doctor approaches their practice:
8
What are the classifications for types of foreign body injury?
9
10
What can be the legal implications in such a case?
How would you determine the type of foreign body injury?
Doctor as a professional:
11
When should a general practitioner attempt to remove a foreign body from and
eye and when should he refer?
12
What specific foreign body injuries must be referred to the ophthalmologist?
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Loss of Vision
What is Loss of Vision?
Loss of vision involves not only the eye but also the central elements of the visual apparatus
and can therefore be subdivided anatomically into three subgroups:



Anterior to optic chiasm
Chiasmal
Posterior to chiasm
Lesions anterior to the chiasm, affecting the eye or optic nerve, are likely to produce visual
loss in only one eye (or one eye at a time), whereas chiasmal lesions usually lead to
bitemporal field involvement and retrochiasmal lesions tend to produce hemianopic field
defects – see Phase 2 study guide for anatomical site of neurological lesions and associated
field defects.
Loss of vision can also be divided temporally into acute visual loss and gradual visual loss.
Conditions which cause acute visual loss, ie within a few minutes to few hours, should be
treated as ophthalmic emergencies.
Important Aspects of History







Speed of onset - acute or gradual
Extent of visual loss - total/central/partial/hemifield
One eye or both eyes affected
Other ocular symptoms - photopsia/flashing lights
 “floaters”
 metamorphopsia
 ocular pain - consider differential of acute red eye
Systemic symptoms e.g. headache and jaw claudication (GCA) or vomiting
(acute glaucuma)
Systemic disease
 Hypertension
 Diabetes
 Cardiovascular disease
Previous ocular history
 Myopia
 Hypermetropia
 Injury
 Surgery
Acute Loss of Vision
Common Causes of Persisting Painless Acute Total/Subtotal Loss of Vision In One Eye:

Ischaemic optic neuropathy - may be arteritic (giant cell arteritis) or nonarteritic (atherosclerotic).


Central retinal artery occlusion of large branch retinal artery occlusion.
Central retinal vein occlusion or large branch retinal vein occlusion.
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These causes are usually vascular in aetiology and patients should be investigated for risk
factors in order to help prevent further episodes e.g. smoking, hypertension, diabetes, raised
cholesterol.
Less common but equally important acute or subacute causes of visual loss in one eye:

Vitreous haemorrhage (trauma/retinal detachment/diabetic retinopathy)



Retinal detachment
Retrobulbar neutritis (may be associated with mild degree of pain)
Cerebral infarction involving optic tract, radiation or occipital cortex – field
defects that may be interpreted as uni ocular visual problems.
*NB. Amaurosis fugax: by definition is a transient loss of vision in one eye lasting usually
only a few minutes and at most a few hours - essentially a TIA involving the eye and usually
secondary to embolic event from carotid or heart.
Immediate Management of Sudden Loss of Vision
These conditions should all be treated as ophthalmic emergencies and the importance of
excluding giant cell arteritis cannot be overstated in relation to sudden loss of vision.
Clinical and Laboratory Investigations (see 3rd year study guide)
Students must be familiar with the symptoms, fundal appearances, and management of all
these conditions.
Gradual Loss of Vision





Age related macular degeneration (AMD)
Primary open angle glaucoma (POAG)
Cataract
Diabetic retinopathy/maculopathy
Refractive error
These are very common conditions which the student/graduate will encounter in general
medicine, accident and emergency, general practice etc.
Age Related Macular Degeneration (AMD)
This may be of very gradual onset, or if associated with sub-retinal neovascularisation and
haemorrhage, may present rapidly over a few days to weeks with profound loss of central
vision. Students should be aware of the difference between “dry” and “wet” macular
degeneration, the progression of the disease and the use of the AMSLER grid.
AMD is one of the most common reasons for blind registration in adulthood in this country.
The prevalence (for all degrees from minor to severe) of AMD rises from approximately 2%
in the 54-64 year old age group to almost 30% in the 75-85 year old age group.
Students should be familiar with the fundal appearances, symptoms, possible treatments
and prognosis.
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Primary Open Angle Glaucoma (POAG)
The association of an open anterior chamber angle, raised intra-ocular pressure (normal 1121mmHg), “cupping” of the optic disc (students should recall CDR ratios) and progressive
characteristic loss of visual field, characterise primary open angle glaucoma. This is a
common disease which causes gradual progressive field loss if left untreated, it is often
picked up by optometrists when patients are being examined for spectacles. It affects
approximately 1% of persons between 60-70 years of age and 3% of the population over 75
years. Affected subjects may provide a family history and are usually over 40 years of age.
Students should be familiar with optic disc appearance, prognosis, medical management,
and surgical management. The difference between acute closed angle glaucoma must be
clearly understood – see poster in demonstration room and tutorial.
Cataract (Opacity of the Lens)
This is the most common cause of gradual visual impairment, short of blindness, in the
elderly UK population. Indeed, lens opacities which reduce visual acuity to 6/9 or less have
a prevalence of almost 30% in subjects over 75 years of age!
Students must be aware of symptoms, signs and associations of cataract. They should also
have a clear understanding of the surgical management of this condition which they can
impart to patients. Cataract extraction is the most common elective surgical procedure
carried out in the UK with an annual extraction rate of greater than 1% in the over seventies
(see video).
Diabetic Retinopathy
Diabetes affects up to 5% of the population with an approximate 8:1 ratio between type 2
and type 1 cases. Poor control and duration of diabetes are associated with greater risk of
diabetic retinopathy. Diabetic retinopathy remains one of the most common causes of blind
registration in the UK in the working population.
Students should be familiar with the classification of diabetic retinopathy (tutorial and
handout). They should also know about screening, the importance of good diabetic control
and laser treatment
Refractive Error
Refractive error, or need for glasses, causes a reduction in vision which can be corrected
with the use of the appropriate spectacles. Patients may be unaware of their requirement for
glasses and complain of gradual reduction in vision.
Myopia of greater than -8.0 to -10.0 Dioptres is frequently associated with a number of
degenerative ocular conditions which may lead to severe visual impairment including:
myopic macular degeneration; primary open angle glaucoma, cataract and retinal
detachment.
Defining Visual Impairment
Students must familiarise themselves with the following: Blind registration, partial sight
registration, legal requirements to drive, local services for the visually impaired, the role of
low visual aids.
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What Should I Do?





Understand and prioritise the common causes of acute visual loss


Understand the impact of loss of vision in the family and community
Understand and prioritise appropriately the more gradual forms visual loss
Be acquainted with visual prognosis in order to inform patient
Be aware of legal definitions and restrictions related to visual loss
Have a knowledge of support services eg partial sight/blind registration;
blind societies; low visual aid provisions; guide dogs for the blind
Understand blindness prevention.
Where Can I Learn About Loss of Vision?



Review Phase 2 lectures on the eye in systemic disease and visual loss.

There are always subjects with cataracts on the eye wards and ophthalmic
theatre.


A video on cataract is available.

Since many of these conditions frequently affect the elderly, students should
take the opportunity to examine the eyes of the patients when on medical,
surgical and community attachments.
Tutorials will be provided on aspects of this study guide.
Patients with these conditions will be seen in the ophthalmic emergency
room and outpatients clinics.
An afternoon visit to the Visually Impaired Society (Ward Road) will provide
first hand practical information about blindness in the community.
How Do The Curriculum Themes Contribute?
Visual loss is directly related to many other components of the medical curriculum. Students
should review the anatomy of the visual pathways and cerebral/ocular blood supply. Visual
loss may be associated with common medical disorders including diabetes, hypertension,
cardiovascular disease. Since visual loss of gradual onset primarily and maintaining
independence in the ageing population. Disease prevention by early identification and
appropriate management of early diabetic retinopathy or early glaucoma is important. Since
visual loss involves not only the eye but the central visual apparatus there is a significant
degree of overlap with neurology themes.
Recommended Reading



ABC of Eyes, Khaw & Elkington, BMJ publishing group, ISBN 0 7279 0766 2
Practical/lecture notes from Phase 2 ophthalmology course
Surgery 2 Ophthalmology – Section 3, Dent JA, Churchill Livingston 2007
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Problem as seen by the Doctor
Loss of Vision
Problem as experienced by your patient
_______________________
System links
Special Senses - Eyes/Neurology
What a doctor will be able to do:
1
What are the important aspects of the history? What signs would you actively
look for on examination?
2
Are you familiar with use of VA (Snellen) chart in your practice?
3
How would you investigate a patient with acute loss of vision in one eye?
4
What issues would require to be considered in setting up a blindness prevention
programme in the over 60s?
5
What communication issues would arise from the following:


78 year old widow with cataracts following a fall,
45 year old pilot with episode of acute unilateral loss of vision?
How did you explain to your patient and family the prognosis of their condition?
6
Are you familiar with the current SIGN guidelines on loss of vision and cataract
surgery?
How a doctor approaches their practice:
7
How can loss of vision be subdivided into three anatomical subgroups, which
relate clinical presentation to location of the lesion?
8
What are the current legal definitions and restrictions related to visual loss?
9
How would you differentiate between the following:


causes of gradual painless loss of vision
causes of acute painless loss of vision?
Doctor as a professional:
10
What significant role with respect to loss of vision does the doctor play in:


11
the primary care setting,
A+E?
What are your criteria for prioritisation of patients presenting with common causes
of loss of vision?
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Painful Red Eyes
Introduction - A Perspective
All the conditions listed below can present as red eyes. As a GP or an A&E doctor which
most medical graduates will be at some point you will see a lot of eye problems and of these
most will be red.
This paper is a useful reference in this topic:
JH Sheldrick, SA Vernon, A Wilson, SJ Read
Demand incidence and episode rates of ophthalmic disease in a defined urban population
British Medical Journal 1992; 305: 933-6.
36,018 people from the combined practice lists of 17 GP surgeries were observed over a
period of 12 months for eye problems presenting to General Practice and Accident and
Emergency departments. Over this period 120,000 presentations took place of which 1771
were for red eye problems. This represents 1.5% (1771 / 120,000) of the total. The
diagnoses which presented are listed below:
Condition
Rate per 1000 of pop.
Infective Conjunctivitis
13.5
Foreign Body
4.7
Allergic Conjunctivitis
4.4
Corneal Abrasion
3.2
Blepharitis/ Chalazion
3.1
Dry Eyes
3.1
Subconjunctival Haemorrhage
1.2
Glaucoma
0.9
Anterior Uveitis
0.6
Other Misc. Conditions
2.6
The Task: How To Make a Diagnosis and What To Do
Why Do You Need To Make a Diagnosis ?
A confident, correct diagnosis will reassure the patient and allow early appropriate treatment.
Rapid resolution of symptoms will reduce the risk of long-term functional impairment.
Delayed diagnosis and incorrect treatment may lead to chronicity and serious damage to
structures of the eye. By the end of your ophthalmology attachment you should have a good
grasp of the differential diagnoses of a painful red eye and the common treatments
employed.
History
It is crucial to understand how and when symptoms started. The circumstance of the initial
awareness of pain or redness may help in a diagnosis of foreign body, abrasion or allergy.
The duration of symptoms is also important; sticky red eye of 3 days duration is likely to be
a bacterial conjunctivitis while a history of 3 months may represent thyroid eye disease.
Associated symptoms can also be useful with itch suggesting allergy, pain and photophobia
characteristic of anterior uveitis and painful loss of vision suggesting acute glaucoma. Past
medical history and current medications also give useful clues. A history of ankylosing
spondylitis may suggest anterior uveitis while a history of cold sores may suggest a herpes
simplex keratitis (HSV). A good history will often be enough to make the diagnosis while an
examination will confirm it.
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Examination
A pen torch and fluorescein drops are required to examine the anterior part of the eye
properly.
Eye lid inflammation should be noted and any form of discharge. The distribution of
redness of the conjunctiva and sclera are suggestive of certain conditions: Localised,
sectorial injection is suggestive of episcleritis or scleritis while peri-limbal injection is
characteristic of anterior uveitis. Corneal epithelial defects will stain with fluorescein.
Superficial dendritic ulcers are characteristic of herpes simplex. Corneal clarity can be
assessed by observation of iris detail. Localised opacification may suggest bacterial
ulceration, a serious condition requiring microbiology investigation, ophthalmic admission
and intensive treatment.
Management
Once a diagnosis is made appropriate, treatment should be started. There are generally two
aims to treatment:

Treat the underlying cause eg aciclovir for HSV, and corticosteroids for
uveitis

Symptomatic treatment eg cycloplegic for photophobia and paracetamol
for pain
By the end of your attachment you should have a good grasp of the differential diagnoses
(see list below) of a painful red eye and the common treatments employed.
How Do The Curriculum Themes Contribute?
Clinical Methods - Precise history taking and simple methodical examination will identify
correctly allergic, chronic inflammatory or infective processes.
Therapeutics – Many red eyes fall into either infective or or inflammatory causes. It is
important to appreciate the potential hazards of wrongly treating infective conditions with
steroids and inflammatory conditions with antibiotics.
Basic Sciences - An understanding of ocular anatomy, physiology, pathology and
immunological processes will explain symptoms, signs and treatment choices.
Health Promotion and Disease Prevention. Many red eye conditions are infective. Advice
regarding washing hands and use of separate towels should be given to patients to reduce
spread of infection. Traumatic red eyes maybe avoided by the appropriate use of eye
protection and machine guards.
How To View The Red Eye : In Context Of Likelihood
A Page Chiapella and A Ralph Rosenthal, One year in an eye casualty clinic. British Journal
of Ophthalmology 1985; 69: 865-870.
This paper recorded all new presentations to a dedicated eye casualty. Below is a list of the
non-traumatic causes of red eye.
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Condition
Acute Conjunctivitis
Eye Lid Disease
Anterior Uveitis
Corneal Ulcer / Keratitis
Scleritis/Episcleritis
Subconjunctival Haematoma
Herpes Zoster
2011/2012
Cases
626
385
183
240
122
115
73
A practical approach to view the red eye would be in order of likelihood. Within A&E, a
general practice surgery or a general medical ward the above conditions are likely to be
similarly represented. Always bear in mind this list.
Where Can I Learn More About Red Eyes?
The treatment room in the outpatient department is the best place to see painful red eyes.
The clinic runs from 9.00 am to 5.00 pm every day. Other attachments which will involve the
red eye are A&E and general practice.
Tutorials will be provided on aspects of the acute red eye.
Review lecture on Red Eyes from Phase 2 Study Guide.
Recommended Reading


ABC of EYES by BMJ publishing is the suggested reference book.
Surgery 2 Ophthalmology – Section 3, Dent JA, Churchill Livingston 2007
(3rd edition)
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Problem as seen by the Doctor
Red Eyes
Problem as experienced by your patient
_______________________
System links
Special Senses - Eyes
What a doctor will be able to do:
1
What were the crucial features in the history?
2
Are you familiar with how to correctly apply fluorescein drops to the eyes?
3
Can you carry out pupillary assessment, eclipse test, estimation of the intra-ocular
pressure?
How would you investigate a patient with a corneal ulcer?
4
What are the two main aims of treatment?
5
What advice can be given to patients with the various causes of red eye to prevent
recurrence?
6
Why is a confident correct diagnosis important for the patient?
7
What additional insights were gained by referring to Brit Med J 1992; 305:
933-6?
How a doctor approaches their practice:
8
What is the relation of the structures of the external eye to the clinical presentation
in your patient?
9
How would you manage a 21 year old male, with a longstanding female partner,
who presents with conjunctivitis and urethritis? (What is Reiter’s syndrome?)
10
How would you differentiate between the common non-traumatic causes of red
eyes?
Doctor as a professional:
11
What is the main task of the junior doctor when dealing with this problem?
12
Who are the members of the health care team who help to ensure high quality of
care?
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Squint (strabismus)
What is a Squint?
A squint (strabismus) is a misalignment of the visual axes of the eyes. A squint is usually
horizontal (the eyes turn inwards – a convergent squint or eso deviation, or they turn
outwards – a divergent squint or exo eviation), but they may be vertical, one eye is
higher than the other (a hyper-deviation) or lower (a hypo-deviation) or maybe torsional,
when the eyes are rotated away (excyclotortsion) or towards (incyclotortsion) each other.
The eye movements are carried out via six extraocular muscles that move each eye. The
brain co-ordinates these muscles so that both eyes work together and people see one image
through both eyes despite using two eyes. The visual pathways lead to crossing of all nasal
fibres (temporal fields) at the optic chiasm and therefore information from both eyes is
blended in the occipital lobes to give a single image from both eyes. Misalignment of the
visual axes therefore tends to cause double vision.
Squint has different causes, clinical features and aims of treatment in children and in adults.
Children
Causes of squint:
In most children a squint represents “developmental” abnormality of the visual system. This
is usually due to the child being long sighted (hypermetropic) and often can be corrected
with glasses.
This type of squint in children is very common – present in approximately 5% of children.
Occasionally squint in children can be due to more serious underlying problems such as
retinoblastoma (a malignant ocular tumour of early childhood which often presents with a
squint) or a nerve palsy which indicates an intra-cranial pathology. Usually however squints
are isolated and not associated with any other problems in children.
Clinical features:
The child is usually asymptomatic, as although they are squinting they have the ability to
suppress (or switch off) one eye to allow them to maintain single vision. Therefore it is
important that children are screened for the presence of the squint, as they have no
complaints. Parents may notice a squint but commonly they appear quite subtle.
On examination squints in children tend to be concomitant (there is no evidence of any
weakness of any of the eye movements and the squint remains the same size in all positions
of gaze). Children with squint may develop amblyopia (loss of vision) in the squinting eye,
which reflects lack of appropriate development of the visual pathways from that eye. There
is a short time in which amblyopia can be treated and this is usually up to the age of eight
years.
Treatment Aims:
Aims of treatment in children are to prevent amblyopia and promote binocular vision (i.e. the
ability to use the eyes together). The former is usually done by patching (occluding) the
good eye to stimulate the squinting eye and the later by improving ocular alignment usually
with glasses but in some cases with botulinum toxin treatment or surgery.
Adults
Causes of squint:
Most adults who develop a squint do so because of a nerve palsy (3rd, 4th or 6th), trauma (eg
blowout fractures) or muscle pathology (for example thyroid eye disease). Remember
children with squints may grow up into adults with squints so adults with long standing
squints do occur which tend to have a benign cause.
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Clinical features:
Adults who develop squints present with double vision (diplopia). This is usually very
troublesome and disabling. Eye movement testing usually reveals some reduction in
movement in one or more directions causing the size of the deviation to vary in different
positions of gaze (an incomitant squint).
Treatments Aims:
The aims of treatment are elimination of double vision using a patch (covering one eye to
cut out the second image) or a prism to give the patient comfort. Many cases spontaneously
improve but some require surgery or botulinum toxin – this is usually performed after a few
months.
Investigation of the underlying cause of the squint involves a full history and a systematic
enquiry and examination especially for micro-vascular risk factors, neurological and
endocrine disease.
Why is Squint Important?
Squint is important because it is commonly indetected in children and may lead to loss of
vision (amblyopia), which is only correctable up until the age of eight.
It is also important because it may be associated with neurological or visual pathway
abnormalities particularly in adults.
How To Diagnose - And What To Do With - A Squint In The Community
Children:
Squint can be present in infancy or early childhood. The majority present between 18
months and 4 years as this is the time in which the development of binocular vision takes
place. Detection and treatment of refractive error (requirement for glasses) are important
factors.
Adults:
Adults usually present with diplopia and therefore attend their doctor due to this problem.
History
Children:
Age of onset (usually between 18 months and 4 years). Variability (worse when the child
is tired or ill) intermittent or constant. Is it always one eye or does the squint alternate? Is
there any associated (compensating) head tilt or turn? Double vision suggests recent
onset (before “suppression” becomes active) and a paretic component (ie weakness of eye
movement in one or several positions of gaze) suggest nerve palsies and neurological
disease.
 Family History
 Strabismus is frequently runs in families.
 Examination
 Examination of a squint requires examinations of the eye movements and the cover
test. There are as well covered in recommended texts and a session on this during
the block. Document any abnormal head posture before commencing examination of
the eyes, examination of which should include knowledge about the cover test and
how to examine eye movements. It may be relevant to carry out a full neurological
examination with particular attention to the cranial nerves.
 Referral
The majority of children are appropriately considered routine referrals. Any atypical
features - such as incomitance or loss of the red reflex, should justify a more urgent
referral. Any associated neurological findings render the referral as urgent.
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Adults:
All factors pertaining to general systematic enquiries should be pursued particularly
regarding vascular, neurological or endocrine disease.

Examination
 Examination of squint involves cover test and eye movements.
 Referral
Adults should be referred to the eye clinic comments with previous discussion with an
Ophthalmologist.
What Should I Do?


Be able to correctly detect and prioritise a squinting patient.

Know an atypical squint (lack of red reflex, lack of full eye movement) may
reflect a more sinister pathology.

Be aware of the importance of the onset of double vision in an adult.
Be able to be able to give the parents a likely idea of what treatment will be
pursued in the ophthalmology department.
Recommended Reading

ABC of Eyes, Khaw & Elkington, BMJ publishing group, ISBN 0 7279 0766 2
In Library Page 42 et seq.

Surgery 2, Section 3 (Ophthalmology), Dent JA, Church Livingston 2007 (3rd
edition)
Further Reading

“Clinical Ophthalmology” J Kanski, Butterworth-Heinemann, ISBN 0 7506
1429 3, In Library, Page 411 et seq.

“Manual of Ocular Diagnosis and Therapy” Pavan-Langston, Little Brown
Spiral Manual, ISBN 0 3166 9547 5, In Library, Page 295 et seq.
Self Assessment
The mother of a three year old comes to see you convinced her son is beginning to squint
when “reading”. You should be able to describe how to examine and investigate the child,
have a likely idea of the most probable findings, and know how to appropriately refer the
child, if you think it necessary.
A 75 year old man presents with sudden onset of double vision. This is side by side and the
images become further apart when he looks to the left. The left eye does not move out fully
to the left on examination. Discuss the cause of the problem and the possible underlying
causes, the investigation and management.
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Problem as seen by the Doctor
Squint in Children
Problem as experienced by your patient
_______________________
System link
Special Senses - Eyes/Neurology
What a doctor will be able to do:
1
What are the relevant features of the history from your patient (negative and
positive)? Describe the relevant physical examination you carried out.
2
Can you examine the patients eye movements?
3
What investigations are needed in a patient with an incomitant squint?
4
How would you manage a squint in a child aged 3 years?
5
How can deterioration in vision from strabismus be prevented?
With whom and what should be discussed in relation to a child with suspected
retinoblastoma and to an adult with double vision and pupiliredenia?
6
How a doctor approaches their practice:
8
How does the brain co-ordinate the function of the extraocular muscles to achieve
a co-ordinated vision of the world?
9
Who should be referred from the primary care setting and how could this process
be monitored? Explain in relation to your patient’s experience?
What is the relationship between visual function and ocular alignment?
10
How can you differentiate between whether a strabismus is a neurological or
visual pathway disturbance or an isolated phenomenon?
Doctor as a professional:
11
How do the roles of doctor, optometrist and orthoptist interface in the
management of squint?
12
Consider how assessment of eye movements and use of the cover test in adults
had utility in diverse aspects of medical practice including neurology, accident
and emergency, general medicine and general practice.
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Medical School