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Eye Essentials For General Practice Davina Sehgal Presentation Content • Brief introduction • Common ocular symptoms • • • • • Red Eye Painful / Itchy Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches • Primary Open Angle Glaucoma • Ophthalmoscopy Technique • Q&A Introduction • Practicing for over 8 years • Work as locum based in the Observatory in Muswell Hill • Eye problems account for 2% of all GP consultations Common Ocular Symptoms • • • • • Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches Red Eye Red Eye • • • • • • • Subconjunctival Haemorrhage Bacterial Conjunctivitis Viral & Allergic Conjunctivitis Iritis – Uveitis Scleritis & Episcleritis Foreign Body Closed Angle Glaucoma Subconjunctival Haemorrhage Subconjunctival Haemorrhage • The only type of red eye which has no symptoms • Conjunctiva has bright & solidly red appearance • Most common reason is idiopathic, no need to refer • Carry out full blood check if it happens recurrently due to risk of high BP Bacterial Conjunctivitis • One of the most commonly encountered eye problems in medicine • A sticky, yellow, mucousy eye discharge • Can be severe enough to cause the eyelids to be stuck together on awakening • Conjunctiva has a pinker appearance compared to subconjunctival haemorrhage • Chloramphenicol Viral Conjunctivitis • Can be difficult to differentiate from bacterial • No discharge, just watering • The signs on ophthalmic exam which suggest viral over bacterial: • Follicles on tarsal conjunctiva (look like translucent rice grains!) • Concurrent pharyngitis, fever, and upper respiratory infection • Patients will often have symptoms of a common cold • No eye drops or ointments are effective against the common viruses that cause viral conjunctivitis Viral Conjunctivitis Iritis – Uveitis • Uvea = iris, ciliary body & choroid • Important deferential diagnosis from conjunctivitis • Presents with fairly sudden onset painful (dull ache), red eye with photophobia and reduced vision • Symptoms can therefore be similar to conjunctivitis but headache just above affected eye common. May also see a small or distorted pupil relative to the other eye. • Sometimes an increase in floaters due to aqueous cells & flare Iritis – Uveitis • Usually unilateral • If left untreated, posterior synechiae can form (adhesions between the anterior surface of the capsule of the lens and the iris) causing iris bombe which can raise IOPs • If these are extensive they may impede the normal flow of aqueous leading to the peripheral iris being pushed forwards and causing iris bombe, raising IOPs. • Tends to affect middle aged or younger people, especially men (not common in children) Iritis – Uveitis • Can be associated with certain autoimmune disorders such as rheumatoid arthritis or ankylosing spondylitis • EMERGENCY! Episcleritis • Inflammation of the episclera (lies between the conjunctiva and the sclera) • Usually benign & idiopathic • Localised area of redness • No or very mild discomfort/grittiness • Lasts approx 7-10 days before spontaneously resolving • Treatment is not usually required but artificial tears may provide some relief Scleritis • More severe inflammation that occurs throughout the entire thickness of the sclera • Boring pain developing gradually & eventually becoming severe. Usually bilateral • Eye may be tender to touch, no discharge • May be associated with connective tissue disorders and autoimmune disorders like rheumatoid arthritis, ankylosing spondylitis & Crohn’s disease • One in six people with scleritis have rheumatoid arthritis - however, only about 1% of people with rheumatoid arthritis will develop scleritis, usually if the arthritis is severe. Scleritis • Topical non-steroidal anti-inflammatory drugs in symptomatic patients • Same day referral to eye hospital Foreign Body • • • • FB sensation Redness, pain, watering Photophobia Use fluorescein if you can & blue filter on ophthalmoscope • Patients are fairly reliable at locating the FB • Flush with fluorescein then refer as emergency Closed Angle Glaucoma • • • • Sudden severe eye pain Blurred vision due to hazy cornea Bright halos appearing around objects. Eye redness & tenderness (ciliary flush, ie the redness is more marked around the periphery of the cornea) • Feeling nauseated and vomiting • Non-reactive (or minimally reactive) mid-dilated pupil. Closed Angle Glaucoma • IOP’s severely raised • More likely to occur in hyperopic patients & when pupil is dilated • Refer to eye hospital as emergency! • Can administer Pilocarpine (miotic) in mean time Common Ocular Symptoms • • • • • Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches Itchy & Watery Eye Itchy & Watery Eye • Allergic conjunctivitis • Affects both eyes • Presence of papillae • Most common cause of watery eyes…. Dry eyes! • Don’t forget to check lids & lashes: • Blepharitis • Meibomian Gland Blockage • Entropian Common Ocular Symptoms • • • • • Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches Reduced Vision (Sudden or Gradual) Reduced Vision (Sudden) • • • • • Sudden onset loss of vision is usually vascular! Central retinal artery occlusion Central retinal vein occlusion Vitreous haemorrhage Ischemic optic neuropathy (Blockage of an artery to the optic nerve) • Giant Cell Arteritis • Carry out a full blood check Reduced Vision (Gradual) • Cataract!! • Red reflex of ophthalmoscopy less bright • Nuclear, cortical, posterior subcapsular – different appearances • Age! Trauma, diabetes, medications such as steroids Common Ocular Symptoms • • • • • Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches Flashing Lights / Floaters Flashing Lights / Floaters • Very common! • 3 main causes • Ocular migraine • Posterior vitreous detachment (PVD) • Retinal detachment (most rare but needs to be ruled out!!) • • • • Sudden onset ring-shaped floater typically PVD Px needs to be dilated ASAP 95% of PVDs have no complications BUT for 3 months after a PVD there is an increased risk of a retinal tear forming (in 5% of cases a retinal tear develops) Retinal Tear / Detachment Common Ocular Symptoms • • • • • Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches Headaches Headaches • If ocular related most commonly frontal • Most commonly associated with change in Rx or ocular muscle imbalances • Headaches associated with eye pain: • • • • Acute Glaucoma Uveitis Viral conjunctivitis Papilloema • Always check optic disc!! Primary Open Angle Glaucoma • Damage to the optic nerve normally caused by raised IOP's, causing irreversible visual field loss • No symptoms! • FH must have annual ST, NHS ST for 40 years & over • Advise regular ST! Case Study • • • • Age/Sex/Race 33 year old male Chief Complaint “My right eye has been red for past three days. It started in the evening three days ago. It was watery and I have dull, throbbing pain.” • The patient is light sensitive. No signs of itching, burning or flashing lights. Gets the occasional floaters but always has done. • Ocular History • The patient said that she knows that she needs glasses for distance but hasn't seen an Optometrist for a few years. • Medications - None • Family History • Mother – Gout, Rheumatoid Arthritis Case Study • What further questions will you ask the patient & what tests will you carry out? • Extraocular muscles: Full • Pupils: PERRLA, No RAPD but RE pupil slightly distorted • Slit lamp examination: • Lids/lashes – clear • Conjunctiva – General bulbar redness with circumlimbal injection LE, clear LE • Cornea – mild edema OD, clear OS (slightly hazier red reflex compared with LE). Case Study • On questioning: Px has not noticed a deterioration in vision but on VA testing, is surprised to see that the RE has reduced to 6/12. Dull ache over RE since yesterday. • ANTERIOR UVEITIS • SAME DAY REFERRAL TO MOORFIELDS OR NEAREST EYE HOSPITAL!! Case Study 2 • Px attends c/o headaches..., you check optic discs & find this: • What does it mean? Q&A Ophthalmoscopy Technique • Start on black +10 lens at about 10cm from patient • Should always be a bright red reflex (unless presence of media opacities) • Click downwards (ie reduced power of lens) & locate a blood vessel • If you increase the negative (or red) numbers, you will focus in objects further away. • Follow blood vessel as it get thicker, lead you to optic disc • Move nasally to find macula • 8 positions of glaze to see periphery, will probably have to adjust lens