Download List of amendments in this update

Australian College of Rural & Remote Medicine
Rural Clinical Guidelines
OPHTHALMOLOGY
Australian College of Rural and Remote Medicine
Rural Clinical Guidelines
ACRRM – July 2012
Note: As these guidelines have been specifically designed to be used on a mobile/smartphone device
or as an online activity on https://www.rrmeo.com you will find that there are numerous hyperlinks that
you will not be able to access in this .pdf document.
To further enhance the usability of the guidelines this .pdf version now has hyperlinks ‘from and back
to’ the ‘Table of Contents’ and is suitable to download onto your computer or any of the smaller iPad,
Tablet, Notebook etc. using your e-reader.
As each discipline is a separate file it is suggested that you also download the ‘Alphabetical List’ of
the guidelines to enable easy cross reference to guidelines in other disciplines.
For a list of all the abbreviations used in these guidelines download the ‘Abbreviations List’.
Table of Contents
End-user licence agreement for ACRRM Mobile Device Clinical Guidelines ............................................................................ 3
List of amendments in this update ............................................................................................................................................. 4
RRMEO Modules ...................................................................................................................................................................... 5
ACKNOWLEDGEMENTS ......................................................................................................................................................... 9
7 POINT EXAMINATION ......................................................................................................................................................... 10
ALLERGIC CONJUNCTIVITIS ................................................................................................................................................ 11
BACTERIAL CONJUNCTIVITIS .............................................................................................................................................. 12
CHEMICAL INJURIES ............................................................................................................................................................ 13
CHILDHOOD EYE DISEASES - (Severe) ............................................................................................................................... 14
CONTACT LENS KERATITIS ................................................................................................................................................. 15
CORNEAL ABRASIONS ......................................................................................................................................................... 16
DENDRITIC ULCER ................................................................................................................................................................ 17
DIAGNOSIS GUIDE ................................................................................................................................................................ 18
EYE INFECTIONS .................................................................................................................................................................. 19
EYELID MALPOSITION .......................................................................................................................................................... 20
EYELIDS ................................................................................................................................................................................. 22
EYES - MISCELLANEOUS ..................................................................................................................................................... 23
FLASH BURNS ....................................................................................................................................................................... 24
FLOPPY EYELID SYNDROME ............................................................................................................................................... 25
FOREIGN BODIES (FB) ......................................................................................................................................................... 26
GLAUCOMA ............................................................................................................................................................................ 27
HERPES ZOSTER .................................................................................................................................................................. 31
IRITIS ...................................................................................................................................................................................... 32
ITCHY EYES ........................................................................................................................................................................... 33
LOSS OF VISION - (GENERAL) ............................................................................................................................................. 35
LOSS OF VISION - (SUDDEN) ............................................................................................................................................... 37
SUBCONJUNCTIVAL HAEMORRHAGE ................................................................................................................................ 39
TRAUMA ................................................................................................................................................................................. 40
UNILATERAL RED EYE ......................................................................................................................................................... 43
VIRAL CONJUNCTIVITIS ....................................................................................................................................................... 44
ACRRM Rural Clinical Guidelines – Ophthalmology – Version July 2012
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End-user licence agreement for ACRRM Mobile Device Clinical Guidelines
1. Introduction
(i) The terms and conditions stated here are in addition to the terms and conditions of the End-User
Licence Agreement for licensees of ACRRM software (Software Licence Agreement) which also apply
to your use of these Mobile Device Rural Clinical Guidelines (Guidelines).
2. Acknowledgement
(i) The Guidelines were developed by the Australian College of Rural and Remote Medicine (ACRRM).
3. Intellectual property rights
(i) The Software Licence Agreement is a legal agreement between the customer and ACRRM which
sets out the terms and conditions of this legal agreement. By clicking on 'Accept' and downloading the
Guidelines you have agreed to be bound by the terms and conditions of the Software Licence
Agreement.
4. Permitted users
(i) The Guidelines are for use only by health professionals who are currently enrolled in the ACRRM
Clinical Guidelines for PDA User Group on ACRRM's www.rrmeo.com website (Permitted Users). The
Guidelines may not be transmitted to or distributed to or used by other persons.
5. Permitted uses
(i) A Permitted User may download, store in a cache, display, print and copy the material in unaltered
form only. The Guidelines may not be transmitted, distributed or used by any other person, or
commercialised without the prior written permission of ACRRM.
6. Updating of Mobile Device Clinical Guidelines
(i) The Guidelines may be updated from time to time. We may advise you by email from time to time if
new versions of the Guidelines become available however you are responsible for checking whether
you have the most recent version. The most recent version of the Guidelines is available on the
ACRRM Clinical Guidelines for PDA User Group webpage on www.rrmeo.com. We disclaim all liability
arising from your failure to download updates of the Guidelines.
7. Seek independent advice
(i) The Guidelines are intended to aid Permitted Users in the management of their patients but do not
provide explanations as to the conditions or treatments outlined. There may be clinical or other
reasons for using different therapy. In all cases, users should understand the individual situation and
exercise independent professional judgment when assessing therapy based on these Guidelines.
Users should seek independent advice.
(ii) The Guidelines do not include comprehensive drug information. Drug usage and doses should
always be checked prior to administering drugs to patients.
(iii) Every effort has been made to ensure the validity and accuracy of the information in this
adaptation of the Guidelines however Permitted Users should at all times exercise good clinical
judgment and seek professional advice where necessary. Treatment must be altered if not clinically
appropriate.
(iv) This adaptation of the Guidelines is presented as an information source only and provided solely
on the basis that users will be responsible for making their own assessment of the matters presented
herein. Users are advised to formally verify all relevant representations, statements and information
from appropriate advisers as it does not constitute professional advice and should not be relied upon
as such.
(v) To the extent permitted by law, ACRRM expressly disclaims any responsibility and all warranties,
express or implied, and excludes liability for all loss (including consequential loss) whatsoever that
may result in any way, directly or indirectly, from the use or reliance upon the Guidelines.
Process: For detailed referencing of the guideline sources, please see the acknowledgements page in
the individual guidelines.
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OPHTHALMOLOGY
List of amendments in this update
New:
Glaucoma
- Open Angle Glaucoma
- Closed Angle Glaucoma
Amended:
Allergic Conjunctivitis
Bacterial Conjunctivitis
Corneal Abrasions
Dendritic Ulcer
Flash Burns
Herpes Zoster
Iritis
Subconjunctival Haemorrhage
Trauma - Eye
Viral Conjunctivitis
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OPHTHALMOLOGY
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RRMEO Modules
Note: This section of the 'ACRRM Clinical Guidelines' is for the sole purpose of assisting users to locate other
educational resources relevant to the ACRRM Curricula statements and to use them as a reference tool only.
You are again reminded that your knowledge acquisition must still be via the directives set out in each of the
ACRRM curricula statements.
This list of modules can be accessed via RRMEO
- to enrol go to RRMEO: https://www.rrmeo.com - Educational Inventory/RRMEO Modules
Note: Abbreviations used:
ATSI = Aboriginal and Torres Strait Islander Health
AIM = Adult Internal Medicine
Anaes = Anaesthesia (JCCA, advanced rural skills)
EM = Emergency Medicine
GEM = Generalist Emergency Medicine (GEM) (Post-Fellowship program)
MH = Mental Health
Obs = Obstetrics and Gynaecology (DRANZCOG Advanced)
Paeds = Paediatrics
Pop = Population Health
RM = Remote Medicine
Surg = Rural Generalist Surgery
Module Name
Suggested Curricula relevance
An Introduction to Digital Photography and Videography
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
Antenatal Care
ATSI
MH
Obs
RM
Best Care Guide to Stroke Management in General Practice:
Module 1
- Transient Ischaemic Attack (TIA) and Early Assessment
Module 2
- Antiplatelet Therapy for Secondary Stroke Prevention
Module 3
- Preventing Fatal and Disabling Stroke in Patients with Atrial Fibrillation
ATSI
AIM
EM
GEM
MH
RM
Breast Cancer
- How not to miss a breast cancer / the triple test in practice
Breast cancer diagnosis
- What now?
Breast cancer treatment
- Managing the impact
Breast cancer treatment is over
- What's next?
ATSI
AIM
EM
GEM
MH
Obs
RM
Surg
Education Program in Cancer Care
(EPICC)
Module 1A
- General Principles of Cancer Care
Module 1B
- Types of Cancer Treatment
ATSI
AIM
Anaes
EM
GEM
MH
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Module 1C
- Cancer Diagnosis
Module 1D
- Multidisciplinary Care Teams
Module 2
- Side Effects of Treatment and Symptom Management
Module 3
- Oncological Emergencies
Module 4
- Psychosocial Care
Module 5
- Follow Up
Obs
Paeds
RM
Surg
General Practitioners Guide to Parkinson's Disease
ATSI
AIM
EM
GEM
MH
Obs
Paeds
RM
Introduction to
Cultural Awareness
ATSI
Pop
RM
Introduction to
Dental Emergencies
ATSI
Anaes
EM
GEM
Paeds
RM
Surg
Introduction to
Population Health
ATSI
EM
GEM
MH
Obs
Paeds
Pop
RM
Mx of Autism Spectrum Disorders in Childhood and Adolescence
Module 1
- Clinical Aspects and Diagnosis
Module 2
- Treatment and Ongoing Management
Module 3
- Special Challenges
ATSI
Paeds
RM
Mx of
Secondary Lymphoedema
ATSI
AIM
Paeds
RM
Surg
Non-Directive Pregnancy Support Counselling Training
ATSI
Obs
RM
Opioid Medication in Palliative Care
ATSI
AIM
Anaes
EM
GEM
MH
Paeds
RM
Surg
Palliative Care
- Choose Your Own Adventure
ATSI
AIM
MH
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Paeds
RM
Palliative Care in
Aged Care Homes
- Palliative Care Australia
ATSI
AIM
MH
RM
Radiology Online
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
RM
Surg
RANZCP - IMG Orientation
Module 01
- Components of Australian health care
Module 02
- Subspecialties of psychiatry
Module 03
- Professional expectations, your responsibilities & rights
Module 04
- Patient & community expectations
Module 05
- Mental health care in a multicultural community
Module 06
- Aboriginal & Torres Strait Islander mental health care
Module 07
- Gender & sexuality
Module 08
- Mental health in rural & remote Australia
Module 09
- Funding & payments
Module 10
- Mental health legislation & regulation
Module 11
- Psychiatric treatment in Australia
Module 12
- Current issues in mental health policy & Australian psychiatry
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
Renal Failure
ATSI
AIM
Anaes
EM
GEM
Paeds
RM
Surg
Retrieval Medicine
- Advanced
- Basic
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
RVTS
Mental Health Disorders Package
for
Rural Practice Core
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
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Sexual Health
- taking a sexual history and managing STI's
ATSI
AIM
EM
GEM
MH
Obs
RM
Tele-Derm National
ATSI
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
Tele-Tox
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
The Beginnings of
Practice Management
RM
Women's Health
- Contraceptive Options in the Bush
ATSI
Obs
RM
(Back to Top)
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OPHTHALMOLOGY
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ACKNOWLEDGEMENTS
These guidelines have drawn extensively on the Emergency Medicine Department protocols developed for Cairns
Base Hospital by Dr Peter Periera and generously made available by him to this project.
A further valuable source was "The ABC-D of Rural Emergencies" by Dr Ian Spencer.
They have been reviewed and expanded by Dr Ramin Zadeh
Reviewers:
Dr Ramin Zadeh - Ophthalmologist, Cairns
Dr Peter Kyriakides - Atherton
Dr David Simonds - Atherton
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OPHTHALMOLOGY
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7 POINT EXAMINATION
See Also - TRAUMA
1. Visual acuity (may need to use topical anaesthetic)
- Snellen chart, object recognition
- record each eye separately
- with & w/o current prescription glasses
- with pinhole if abnormal
2. External examination
- bruises, lacerations, fractures etc
- check for proptosis, eye deviation, lid proptosis
3. Eye movements
- tethering pain on movement & diplopia
4. Pupils
- size & shape, direct & consensual light reflexes
- relative afferent pupil defect (RAPD)
5. Visual fields
6. Anterior Segment - fluorescein stain, slit lamp examination
7. Ophthalmoscopy
- PRESERVATION OF VISION IS OF THE UTMOST IMPORTANCE
- perform examination except in case of chemical contamination where irrigation is first priority
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OPHTHALMOLOGY
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ALLERGIC CONJUNCTIVITIS
Eye & eyelids red & itchy - always bilateral
Conjunctiva may be oedematous
(i) Eye drops eg. olopatadine bd (Patanol)
(ii) Eye drops containing topical vasoconstrictors & antihistamines (eg. Antistin-Privin or Albalon-A) may cause
local irritation if used >2wks
(iii) Oral antihistamines may be useful
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OPHTHALMOLOGY
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BACTERIAL CONJUNCTIVITIS
AIMS
With any suspected corneal infection, if ophthalmologist available urgently then do not start topical Tx.
(allows corneal scraping before Tx)
Obtain specialist advice if ophthalmologist not available
(establish Mx plan)
Beware:
- contact lens wearers
- photophobia
- decreased visual acuity
Bacterial Conjunctivitis:
- redness & feeling of grittiness
- initially unilateral, rapidly becoming bilateral due to cross contamination
- mucopurulent discharge
(i) Eye toilet
(ii) Antibiotic eye drops every 2 hrs during the day & ointment at night for 5 days
(iii) Never pad a discharging eye
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OPHTHALMOLOGY
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CHEMICAL INJURIES
1. Use local anaesthesia & irrigate immediately with N/S (before detailed Hx)
- A morgan lens facilitates irrigation
- Alkali burns must be irrigated for at least 30 mins. & all lime particles removed (requires sweeps of the fornices)
- pH of the eye can be tested with urine test strips being careful to drip ocular secretions onto the strip without
touching the eye
(aim for pH 7.0)
2. Follow with antibiotic ointment & cycloplegic eye drops (eg G homatropine 5% tds)
3. All cases should be admitted or seen asap. by an ophthalmologist
4. Do NOT start steroid drops (small risk corneal stromal melt)
5. Never use topical anaesthetic drops long term (stops corneal healing; may cause infection & blindness)
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OPHTHALMOLOGY
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CHILDHOOD EYE DISEASES - (Severe)
Paediatric Ophthalmology
Important Signs to Remember
Examination
Paediatric Ophthalmology
There are a few conditions that are specific to children
Children usually present with SIGNS rather than SYMPTOMS
Management is different due to immature visual system
Important Signs to Remember
- Optic Nerve Swelling
- Proptosis
- Leukocoria
- Acute onset of Squint
Examination
RAPD
Check the red reflex
Visual Acuity
- objection to cover
- fix and follow
Eye movements
Check for Proptosis
Cover Test
Fundus Examination
Optic Nerve Swelling
- Increased Intra-cranial pressure
- Infiltration
- Infections
- Optic nerve Tumours
- Drusens
Proptosis
- Orbital Cellulitis
- Optic Nerve Tumours
- Orbital Tumours
- Orbital wall dysgenesis
Leukocoria
White Cataract
Retinal lesion
- Chorioretinal Scars
(Toxocara, Toxoplasma)
- Congenital Deformity
(Coloboma)
- Malignant tumours
(Retinoblastoma)
Acute Onset of Squint
- Intra-cranial Pathology must be excluded
By Dr. Ramin Zadeh
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OPHTHALMOLOGY
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CONTACT LENS KERATITIS
AIMS
Severe sight threatening condition
Cornel perforation may occur in 3 days
Risk Factors:
- contact lens wearers
- smokers
- poor lens hygiene
(esp. lens left in overnight)
Organisms:
- pseudomonas aeruginosa (most)
- staphylococcal
- acanthamoeba
Chloramphenicol Tx NOT EFFECTIVE
Dx:
1. Immediate removal lenses
2. Ensure patient keeps lenses and lens case for culture
3. 7 point examination
NB. - not all bacterial keratitis will stain with fluorescein
4. Same day ophthalmologist R/V if epithelial defect or infiltration (opaque zone)
5. Discuss all cases with specialist
Definitive Mx:
Corneal scraping for M&C&S
Antibiotics:
- broad spectrum pending culture
- systemic in severe cases
Reference:
AFP - Vol 36 No 10 October 2007; Pg 831 - The red eye in contact lens wearers - B. Cronin, B. Todd, G. Lee
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OPHTHALMOLOGY
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CORNEAL ABRASIONS
Minor trauma but may be extremely painful
(i) Antibiotic ointment
(ii) Firm double eye pad (optional)
(iii) Daily review until healed
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OPHTHALMOLOGY
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DENDRITIC ULCER
AIMS
With any suspected corneal infection, if ophthalmologist available urgently then do not start topical Tx.
(allows corneal scraping before Tx)
Obtain specialist advice if ophthalmologist not available
(establish Mx plan)
Beware:
- contact lens wearers
- photophobia
- decreased visual acuity
Dendritic Ulcer:
- painful ulcer due to herpes simplex
- appears as a branching pattern on fluorescein staining
(i) Antibiotic ointment & drops to prevent secondary infection
(ii) Steroid drops are absolutely contraindicated
(iii) Commence Acyclovir ointment (topical)
(iv) Refer to ophthalmologist
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OPHTHALMOLOGY
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DIAGNOSIS GUIDE
Test Visual Acuity
If Normal and Pain Low
If Abnormal or Normal with Significant Pain
IF NORMAL AND PAIN LOW (and no corneal ulceration)
(i) IF discharge present consider conjunctivitis (bacterial/viral/allergic)
(ii) Conjunctivitis tends to have initial peripheral sclera redness
(iii) Unilateral red eye is NOT conjunctivitis until all other diagnosis excluded
IF ABNORMAL VA OR NORMAL VA with SIGNIFICANT PAIN
- Examine with fluorescein & slit lamp or ophthalmoscope on +15, +20
(i) Corneal Trauma/Infection
- consider FB
- consider ulcer (traumatic & dendritic)
(ii) Iritis
- small pupil (may not react to light if severe inflammation)
- photophobia
- pain on accommodation
- conjunctival central redness -> 48 hrs can become peripheral
(iii) Glaucoma
- cornea may be cloudy
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OPHTHALMOLOGY
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EYE INFECTIONS
Aims
Bacterial conjunctivitis
Viral conjunctivitis
Herpes zoster
Dendritic ulcer
AIMS
With any suspected corneal infection, if ophthalmologist available urgently then do not start topical Tx.
(allows corneal scraping before Tx)
Obtain specialist advice if ophthalmologist not available
(establish Mx plan)
Beware:
- contact lens wearers
- photophobia
- decreased visual acuity
BACTERIAL CONJUNCTIVITIS:
- redness & feeling of grittiness
- initially unilateral, rapidly becoming bilateral due to cross contamination
- mucopurulent discharge
(i) Eye toilet
(ii) Antibiotic eye drops every 2 hrs during the day & ointment at night for 5 days
(iii) Never pad a discharging eye
VIRAL CONJUNCTIVITIS:
- adenovirus most common & may be assoc. with preauricular rash
- difficult to distinguish viral from bacterial so treat as for bacterial
HERPES ZOSTER:
Form of shingles affecting the nasociliary branch of the trigeminal nerve
- thus if the tip of the nose is affected then the conjunctiva & cornea may also be affected
(i) Refer URGENTLY
(ii) Acyclovir may be indicated (Oral or IV - not topical)
(iii) Topical antibiotic drops (prophylactic)
DENDRITIC ULCER:
- painful ulcer due to herpes simplex
- appears as a branching pattern on fluorescein staining
(i) Antibiotic ointment & drops to prevent secondary infection
(ii) Steroid drops are absolutely contraindicated
(iii) Commence Acyclovir ointment (topical)
(iv) Refer to ophthalmologist
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OPHTHALMOLOGY
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EYELID MALPOSITION
Aims
Common Eyelid Malpositions
Ptosis
Dx
Hx
AIMS:
Beware unilateral changes
--> full Ophthalmological / neurological examination
--> consider referral
COMMON EYELID MALPOSITIONS
Upper eyelid
- Ptosis
- Retraction
- Entropion
Lower eyelid
- Ectropion
- Entropion
- Retraction
PTOSIS
Drooping of upper eyelid due to muscular weakness
Beware serious neurological disease
Dx:
Causes:
Congenital
Aponeurotic
Mechanical
Neurological
Pseudoptosis
(i) Congenital
- levator muscle absence / reduction
- aberrant innervation levator muscle
- Horner's Syndrome
- rare condition
(ii) Aponeurotic
= Dehiscence of levator aponeurosis (tendon connecting levator to tarsal plate)
- spontaneous (commonest acquired ptosis)
- contact lens wear
- post operative (eyelid speculum)
(iii) Mechanical
- excess weight upper eyelid
- infection
- inflammation
- tumours
(iv) Neurological
Muscle:
- mitochondrial myopathy
- oculopharyngeal muscular dystrophy
- myotonic dystrophy
NMJ:
- myasthenia gravis
- Lambert Eaton Syndrome
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- botulinum toxin
Nerve:
- Horner's Syndrome (sympathetic nerve)
(ipsilateral ptosis, miosis, anhidrosis)
- oculomotor nerve
Brainstem:
- intracranial conditions
(v) Pseudoptosis (pathology not in eyelid)
- enopthalmos
- hypotropic eye
- lid retraction in contralateral eye
- dermatochalasis (elderly patients) with redundant eyelid skin & prolapse eyelid fat
- artificial (voluntary)
- floppy eyelid syndrome
Hx:
- congenital / acquired
- acute or slowly progressive
- fatigue (variable)
- associated headache, diplopia
- trauma / ocular surgery / contact lens wear
- family Hx
- old photos --> review
O/E:
Quantify:
Palpebral Fissure
= distance between upper & lower eyelid margins at axis of pupil
(normal 9-12mm)
Margin Reflex Distance
= distance from central pupillary light reflex to upper lid margin
(normal 4-5mm)
General:
Neurological
Ophthalmological
Fatigue (variable ptosis)
Reference:
Medicine Today - May 2010 Vol 11 No 5
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OPHTHALMOLOGY
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EYELIDS
Eyelid Malposition
Floppy Eyelid Syndrome
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OPHTHALMOLOGY
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EYES - MISCELLANEOUS
Allergic conjunctivitis
Flash burns
Corneal abrasions
Iritis
Subconjunctival haemorrhage
ALLERGIC CONJUNCTIVITIS:
- eye & eyelids red & itchy - always bilateral
- conjunctiva may be oedematous
(i) Eye drops eg G olopatadine bd (Patanol)
(ii) Eye drops containing topical vasoconstrictors & antihistamines (eg. Antistin-Privin or Albalon-A) may cause
local irritation if used >2wks
(iii) Oral antihistamines may be useful
FLASH BURNS:
- caused by intense UV radiation from an electric arc welder
- symptoms may be delayed several hrs & include severe pain, blurred vision & tearing
- cornea is pitted (slit lamp)
(i) Local anaesthetic drops (only for assessment - not to take home)
- antibiotic ointment
(ii) A firm double eye pad (optional)
(iii) Oral analgesics
- usually settles 12-24 hrs
(iv) Review daily
CORNEAL ABRASIONS:
- minor trauma but may be extremely painful
(i) Antibiotic ointment
(ii) Firm double eye pad (optional)
(iii) Daily review until healed
IRITIS:
(i) Autoimmune inflammation
(ii) Symptoms
- Blurred vision, photophobia, dull but severe ocular pain which may be referred to temporal area, sclera is red &
pupil may be contracted & irregular
- cells may be seen in AC
(iii) Refer immediately to ophthalmologist for Rx with mydriatic & steroid drops
SUBCONJUNCTIVAL HAEMORRHAGE:
- usually alarming but trivial UNLESS Hx of significant trauma (no posterior limit can be seen to the haemorrhage
in which case there may be an anterior cranial fossa fracture)
(i) CT investigation of choice to exclude penetrating injury, orbital #, base of skull # - as needed
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OPHTHALMOLOGY
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FLASH BURNS
Caused by intense UV radiation from an electric arc welder
Symptoms may be delayed several hrs & include severe pain, blurred vision & tearing
Cornea is pitted (slit lamp)
(i) Local anaesthetic drops (only for assessment - not to take home)
- antibiotic ointment
(ii) A firm double eye pad (optional)
(iii) Oral analgesics
- usually settles 12-24 hrs
(iv) Review daily
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FLOPPY EYELID SYNDROME
Often indicator of obstructive sleep apnoea (OSA)
Dx
Tx
Dx:
- unilateral / bilateral sticky or watery eyes
- worse on waking
- upper eyelid papillary conjunctivitis
- often corneal punctuate keratopathy on fluorescein staining
O/E:
Eversion and exposure of conjunctivitis on placing thumb on upper eyelid and elevating
(normally should not evert)
Tx:
(i) Seek OSA symptoms
- affected eye is side slept on
(if bilateral --> sleeps on both sides of face)
(ii) Tx of OSA
--> refer sleep studies
(iii) Eye protection
-pad, lubrication at night
(iv) Surgery if Sx persist despite OSA Tx
Reference:
Medicine Today - May 2010 Vol 11 No 5
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FOREIGN BODIES (FB)
1. X-ray if chance of penetrating foreign body
- any significant decrease in V/A suggests perforation
2. Use local anaes. & remove FB with 25G needle (easier to handle if attached to syringe)
3. Stain with fluorescein & check for traumatic corneal lacerations or ulcers
4. If not perforated apply antibiotic ointment
- pad not essential (may be better to advise rest)
- apply antibiotic drops during day & ointment at night until healed
5. Check tetanus status
6. Oral analgesia often needed
- pupil dilating drops may also provide significant analgesia
7. Review daily & remove any residual rust as cornea softens
- must be completely removed (may cause severe inflammation)
- refer if persistent rust after a couple of attempts
8. Refer to ophthalmologist if persistent FB involving cornea
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GLAUCOMA
Open Angle Glaucoma
Closed Angle Glaucoma
OPEN ANGLE GLAUCOMA
Aims
Dx
Tx
AIMS
Definition:
Optic neuropathy characterised by progressive visual field loss from peripheral to central vision.
Usually (but not always) associated with raised intraocular pressure.
Screen High Risk Groups:
(i) Regular eye health checks IF
- caucasians >50 yrs old
- african descendants >40 yrs
- first degree relatives of glaucoma patients
(from 5-10yrs before onset in relative)
(ii) Survey for glaucoma IF age >50 yrs AND
- myopia
- abnormal blood pressure
- Hx migraine
- diabetes
- peripheral vasospasm
- eye injury / optic disc haemorrhage
- ongoing steroid use (any route)
(iii) Monitor for glaucoma IF age >70 yrs AND
- IOP > 21mmHg
- large / asymmetric cup / disc ratio
- disc haemorrhage
- thin central corneal thickness
Glaucoma Patients:
- remind first degree relatives to be reviewed
Asymptomatic until central visual field loss (late)
- no loss V/A if central vision preserved
- visual field loss irreversible
Steroid Tx:
- beware in patients with glaucoma
Dx:
N.B.
- Findings from multiple Dxic procedures / tests needed for Dx
- Multiple exams may be needed to set reliable baseline
(i) Medical Hx
- risk factors
- all medications
- co-morbidities (esp. HPT, asthma, thyroid, depression, liver, renal)
- social impact visual dysfunction
(ii) Eye Examination
- anterior segment evaluation and gonioscopy
- optic nerve and retinal nerve fibre exam
-- stereoscopic view
-- permanent record of optic disc / retinal nerve fibre layer
- IOP measurement
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- corneal thickness measurement
(iii) Eye Function - Perimetry
- standard automated perimetry
- age corrected normals
- informed interpretation (large normal variability)
- monitor visual field loss (determine rate of loss)
(iv) Assess Risk of Progression of glaucoma damage
eg. R/V 4 monthly for first 2 yrs then reassess
Tx:
Target intraocular pressure
Monitoring
Medications
Laser / Surgical Tx
1. TARGET INTRAOCCULAR PRESSURE
(i) Suspected primary OAG with high risk
- IOP reduction 20%
- IOP <24 mmHg
(ii) Early / established primary OAG without high risk
- minimum 20% IOP reduction
- IOP <16-19 mmHg
(iii) Established primary OAG with high risk
- 30% reduction IOP
- IOP <15-18 mmHg
(iv) Glaucomatous progression
- further 20% reduction target IOP
2. MONITORING
Seek specialist advice for monitoring intervals
(i) Eye Review (see Dx)
Approx. yearly if stable
More frequently IF
- high risk
- failing to achieve target IOP
(ii) Each Visit
Examination of optic disc looking for
- change
- presence disc haemorrhage
Tonometry
3. MEDICATIONS
N.B. Compliance improved by:
- once daily drops
- fixed dose combinations
- patient information / education
eg. Glaucoma Australia http://www.glaucoma.org.au/
Topical
Comorbidities
(i) Topical
First Line:
- topical prostaglandin analogue
- beta blocker
Second Line:
- carbonic anhydrase inhibitors
Third Line:
- alpha-2-agonists
Initiating / Changing Tx
- use only one eye (other eye = 'control')
- reassess IOP 2-6 wks before treating other eye
- IF Tx ineffective -- substitution is more effective than addition
Instillation of Drops
Demonstrate / educate / observe pt.
Double DOT
= Don't Open Technique
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+ Digital Occlusion of Tear duct
(2-3 mins post instillation)
(ii) Comorbidities
Diabetes
- Beware: B blockers
Depression
- Beware: B blockers, alpha agonists
- consider eye review if high risk prior to commencing antidepressant Tx
COPD / Asthma
Beware: (esp non selective) B blockers
CVS Disease
- Beware: alpha agonists, B blockers
(C/I if - heart block, sick sinus synd, uncontrolled CCF, severe hypotension)
Hepatic / Renal Impairment
- systemic carbonic anhydrase inhibitors
(C/I if severe)
- Beware: topical C. A. inhibitors
Breast Feeding
- Beware: B blockers
- consider laser therapy
4. LASER / SURGICAL Tx
(i) Laser Trabeculoplasty
Alternative OR addition to medication
esp. Older patients at risk of visual loss
PLUS
- difficulty administering drops
- unresponsive to topical Tx
- poor candidates for surgery
N.B.
Require comprehensive glaucoma monitoring as Tx benefit diminishes with time.
(ii) Surgical Tx
At least as effective as medications
Indications
- target IOP not met with 2 medications
- poor compliance to medications
- failed laser Tx
References:
(i) NHMRC Guidelines for screening, prognosis, management and prevention of Glaucoma
(ii) Up to Date: Open angle Glaucoma
Top
CLOSED ANGLE GLAUCOMA
Aims
Dx
Tx
AIMS
Glaucoma = Optic neuropathy with characteristic optic nerve atrophy
Often accompanied by:
- visual field defects
- raised intraocular pressure
Normal Intraocular Pressure = 8-21 mmHg
CLOSED ANGLE GLAUCOMA
Primary:
- anatomically narrow anterior chamber angle
Secondary:
eg. neovascular, mass, haemorrhage, inflammation
Risk Factors:
Family Hx
Age >40
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Hypermetropia
Medications
- OTC decongestants, motion sickness medication
- adrenergics, antipsychotics, antidepressants, anticholinergics
Race (esp. Asian, Inuit)
Dx:
N.B. If rise of IOP is slow, may be Sx free
(see Open Angle Glaucoma)
Sx:
- determined by rapid elevation IOP
- decreased vision + halos around lights
- headache / severe eye pain
- nausea / vomiting
O/E:
- red conjunctiva
- corneal oedema / cloudiness
- shallow anterior chamber
- pupil 4-6mm; reacts poorly to light
- visual acuity decreased
- intraocular pressure
- visual field testing
- undilated fundus examination
(N.B. pupil dilation may worsen condition)
- slit lamp examination anterior segments
DDx: - see Unilateral Red Eye
F - foreign body
I - iritis or episcleritis
G - glaucoma
U - ulcer (esp. dendritic)
T - trauma
Tx:- Consult Ophthalmologist all cases
Lower IOP
Topical:
- Timolol 0.5% (drops)
- Pilocarpine 2% (drops)
Oral:
- Acetazolamide 500mg
- Glycerol
IV:
- Acetazolamide 250-500mg
- Mannitol 1gm / kg IV over 30 mins
Recheck IOP 30-60 mins post Tx
URGENT transfer to specialist care
- definitive Tx is peripheral laser iridotomy
References:
(i) Up to Date: Closed angle Glaucoma
(ii) Australian Medicines Handbook
Acknowledgement:
Thanks to Dr Brian Todd, Ophthalmologist, Cairns.
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HERPES ZOSTER
AIMS
With any suspected corneal infection, if ophthalmologist available urgently then do not start topical Tx.
(allows corneal scraping before Tx)
Obtain specialist advice if ophthalmologist not available
(establish Mx plan)
Beware:
- contact lens wearers
- photophobia
- decreased visual acuity
Herpes Zoster:
Form of shingles affecting the nasociliary branch of the trigeminal nerve
- thus if the tip of the nose is affected then the conjunctiva & cornea may also be affected
(i) Refer URGENTLY
(ii) Acyclovir may be indicated (Oral or IV - not topical)
(iii) Topical antibiotic drops (prophylactic)
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IRITIS
(i) Autoimmune inflammation
(ii) Symptoms
- Blurred vision, photophobia, dull but severe ocular pain which may be referred to temporal area, sclera is red &
pupil may be contracted & irregular
- cells may be seen in AC
(iii) Refer immediately to ophthalmologist for Rx with mydriatic & steroid drops
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ITCHY EYES
Aim
DDx
Tx
AIM
Rarely sight threatening
Specific Dx and Tx
DDx:
Allergic
Ocular surface
Mechanical lid anomalies
Blepharitis
(i) ALLERGIC
Sx
- discharge
- conjunctival redness
- inflamed lids
Hx
- Topical medication / cosmetics
- Allergic - asthma, hayfever, eczema
(ii) OCCULAR SURFACE
eg superficial keratitis
Sx
- local irritation
- tear film disruption
- vision may be impaired
O/E
- V/A
- fluorescein stain
(iii) MECHANICAL LID ANOMALIES
eg Entropion, Ectropion
Sx
- irritation
- tearing
- aggravated by dry / windy conditions
- excessive rubbing (may worsen Sx)
(iv) BLEPHARITIS (inflammation)
Sx
- burning, irritable eyes
- localised swelling of lids
- +/- crusting, discharge
- often worse on waking
Cx
- loss of lashes
- lid scarring & thickening
-> corneal ulceration
-> tear film disruption
-> notching, trichiasis, ectropion, entropion
DDx Chalazions / styes
Viral infection
- molluscum contagiosum
- pox virus
Staphylococcal anterior blepharitis
- collarettes (inflamed hard scales at base of lashes)
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- telangiectasia
- ulceration
Seborrhoeic anterior blepharitis
- lashes waxy, often sticking together
- Dandruff like scale
- Skin changes of seborrhoeic dermatitis
Posterior blepharitis
- dysfunction of meibomian glands
- May be secondary to anterior blepharitis, acne rosacea, dermatitis
- Excess oily waxy secretions (meibomian seborrhoea)
- Blocked / infected glands (posterior meibomianitis)
Tx:
AIMS:
- control Sx
- prevent complications (cycle of inflammation)
Chronic intermittent condition
General
Specific
1. GENERAL
Artificial tears
- alleviate itch
- help washing
Lid scrubs twice daily (Blepharitis)
- warm compresses liquefy secretions
- massage eyelids towards eyelashes
- cleanse lid margins with cotton bud dipped in 1/2 cup cool boiled water + 5 drops baby shampoo
(scrub horizontally at eyelid margin)
- rinse well with water
Counsel patient to follow full course of Tx
- Sx may resolve but base inflammation persist
2. SPECIFIC
Allergic
Mechanical Lid Anomalies
Blepharitis
Allergic
- avoid irritants
- topical antihistamines / vasoconstrictors
(eg Antistin-Privin or Albalon-A)
Mechanical Lid Anomalies
- may require surgical Tx
Blepharitis
- General Tx (above)
- Chalazions / Styes may require surgery
- Staphylococcal anterior blepharitis
Chloramphenicol ointment (1 wk)
Hydrocortisone ointment if very inflamed (1 wk)
- Oral tetracyclines (may need long term or intermittent courses)
NB Contraindicated pregnancy, < 8 year old. May cause photosensitivity, GI side effects. Interfere with OC pill.
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LOSS OF VISION - (GENERAL)
See also - Loss of Vision - Sudden
Aim
Hx
Exam.
Ix
Aim:
At what level is the visual loss?
- Cortical
- Optic Nerve
- Retina
- The clear media (vitreous, Lens)
- Cornea
History
(i) Sudden and Painless Onset
Likely to be a Vascular event
- Cortical
- Ischaemic Optic Neuropathy (ION)
- Retinal (Arterial or Venous)
- Vitreous Haemorrhage
Others
- Retinal Detachment
- Optic neuritis
(ii) Sudden and Painful onset
- Corneal disease (V/A improves with LA)
- Acute Angle Closure Glaucoma (pupils non reactive)
- Uveitis (pupils non reactive)
- Optic Neuritis
(iii) Gradual onset
- Cataracts
- ARMD (age related macular degen)
- Glaucoma
(iv) Other important Symptoms
- Giant Cell Arteritis (GCA) - Jaw Claudications, etc
- Flashes & Floaters (Sx of retinal traction-esp if nocturnal)
- Field loss
(v) General Medical History
- Vascular Disease Risk Factors:
- HT, DM, ^Cholesterol, Smoking
- Systems Review:
- Especially CNS (optic neuritis, other)
Examination
Don't forget general Examination!
- Age
- BP
- Temp
- BSL
- Heart: Murmurs, AF
- Carotid: Bruit
- Palpate TEMPORAL ARTERY
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Eyes
- Visual Acuity - each eye separately, PH
- Fields - is field loss vertical (cortical) or altitudinal (vascular)
or other (?retinal)
- Relative Afferent Pupillary Defect (RAPD)
- Brightness Perception (ask/compare eyes)
- Colour Perception - Red Target (1st colour lost; esp optic N damage)
- Check for Proptosis from above (orbital pathology)
- Look at red Reflex (intraocular pathology)
- Fundus Examination
Investigations
FBE: - Hyperviscosity, Leukaemia
- Giant Cell Arteritis
ESR (85% sensitive), CRP (increases sensitivity to 98%)
- Sarcoidosis, Vasculitis
ACE, ANA, cANCA:
- Cardiovascular:
- Carotid Doppler, echocardiogram (embolic sources)
CNS:
- MRI
By Dr. Ramin Zadeh
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LOSS OF VISION - (SUDDEN)
Vascular
CNS
Toxic
Inflammatory
Structural
Psychiatric
VASCULAR:
1. Retinal artery thrombosis
- sudden painless loss of vision in 1 eye
- eye appears normal
- retina is pale & RA's may not be visible
RX: (within 1hr)
- Aspirin 300mg
- Massage globe of eye
- Rebreathing into paper bag
- Acetazolamide (Diamox) 500mg IV
- Urgent ESR
(if >50 give Prednisolone 100mg)
- Contact ophthalmologist immediately for possible AC paracentesis
2. Retinal vein occlusion
- gradual, painless diminution of vision in 1 eye
- retina congested & blood streaked
- no effective acute RX --> refer ophthalmologist
3. Vitreous haemorrhage
CNS:
1. Cerebrovascular accident
2. Transient ischaemic attack
3. Migraine
TOXIC:
1. Methanol
- ideally pt. should be admitted for ethanol infusion
- may require haemodialysis
INFLAMMATORY:
1. Optic neuritis
- loss of central vision
- optic disk is pale
- assoc. with MS in 25% of cases
- admit / transfer for immediate retrobulbar steroid injection
2. Endophthalmitis
STRUCTURAL:
1. Glaucoma
Clinical features:
- pain
- hazy or lost vision
- haloes around lights
- nausea & vomiting
- tense eye
- cornea is cloudy
- pupil fixed & semi-dilated
Rx: Treat immediately
- Pilocarpine 4% drops every 5mins for 1hr. to both eyes
- Acetazolamide 500mg IV
- analgesia & antiemetics
- transfer for peripheral iridectomy
2. Retinal detachment
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- may be spontaneous or assoc. with trauma
- myopic are predisposed
- pt. may experience flashing lights & floaters followed by sensation of curtain coming down across VF
- nurse flat if detachment is inferior
- nurse head up if detachment is superior
PSYCHIATRIC:
1. Hysteria
- Pt. is inapprop. calm about what should really be a catastrophic event
- eye exam is NAD including pupillary reflexes
- this diagnosis is to be entertained only when all other aetiologies are excluded
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SUBCONJUNCTIVAL HAEMORRHAGE
Usually alarming but trivial UNLESS Hx of significant trauma (no posterior limit can be seen to the haemorrhage
in which case there may be an anterior cranial fossa fracture)
(i) CT investigation of choice to exclude penetrating injury, orbital #, base of skull # - as needed
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TRAUMA
Types
1st Aid
History
Examination
Specific Conditions
TYPES
(i) Open Globe Injuries
- penetrating eye injury
- globe rupture
- intra-ocular FB
N.B.
- mechanism of injury important (esp. metal hammering)
- all require CT scan evaluation
(ii) Closed Globe Injuries
- partial thickness corneal laceration
- hyphema
- vitreous haemorrhage
- retinal tear/detachment
(iii) Chemical Burns
(iv) Traumatic Optic Neuropathy
(v) Orbital Fracture
1st AID (all cases)
- pain relief - IV or IM
- anti-emetics - IV or IM
- antibiotics - IV (cephalothin and gentamicin)
- shield without eye pad, to avoid any pressure on the eye
- fast patient
HISTORY (all cases)
- time and method of injury
- initial vision immediately after injury
- any deterioration since the injury
- any history of previous eye disease, operation or trauma
- tetanus status - treat appropriately
EXAMINATION (all cases)
(i) Visual acuity
- may need topical anaesthetic for patient comfort before checking V/A
- do not forget the other eye
- check with glasses or pinhole
(ii) Light reflexes
- direct
- consensual
- relative afferent pupillary defect
(very important)
(iii) Eyelids
- oedema / bruising
- burns or chemical injury
- lacerations (medial, lateral, lid margin, canaliculi)
- ptosis
- foreign bodies
- avulsion of canthal tendon
(iv) Orbital rim
- step
- subcutaneous emphysema
(v) Globe - retract eyelids without applying pressure
- anterior displacement (retrobulbar haematoma)
- posterior / inferior displacement (orbital #)
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(vi) Check shape of pupil for:
- distortion
- elongation
- obvious iris mutilation
(all indicate open globe injury)
(vii) Check anterior chamber for:
- deepening
- shallowing
- presence of blood (hyphema)
(all indicate significant open or closed globe injury)
(viii) Lens
- check for transparency, dislocation
(ix) Cornea / conjunctiva
- check with fluorescence 2% drops for:
- corneal laceration
- foreign body
- check for leakage of fluid from eye (seidel's test)
(x) Vitreous and retina
- foreign body
- haemorrhage, tears, detachment
(xi) Check eye movement and ask about diplopia
(xii) Check visual fields
(xiii) Check for proptosis
(very important as severe proptosis can lead to optic nerve ischaemia and blindness which is preventable)
IF eyelids are very swollen and you are unable to open eyelids to see the globe then organize an URGENT CT
orbit to make sure that there is no significant proptosis secondary to orbital haemorrhage or globe rupture
SPECIFIC CONDITIONS:
Ruptured globe/penetrating injury
Orbital fracture
Hyphema
Vitreous haemorrhage
Retinal detachment
Traumatic dislocation lens
Traumatic mydriasis
Traumatic iritis
1. Ruptured globe / penetrating injury
- usually within 5mm from limbus
- VA is reduced
- AC may be deeper than good eye
- Rx: analgesia, antiemetics & urgent transfer - shield affected eye
- require CT to exclude FB
2. Orbital fracture
- usually floor & medial wall
- contents of orbit may prolapse downwards & entrapment of inf. rectus muscle leads to diplopia & pain on looking
upwards
- check infra-orbital nerve sensation
(cheek and upper lip/gum)
Management
- fine cut orbital CT
- referral to ophthalmologist or plastic surgeon
3. Hyphema
- make sure there is no evidence of ruptured globe
Management
- admit for strict bed rest
- elevate head at 450
- cycloplegic drops (atropine 1% BD to t.d.s.)
- steroid drops (eg prednefrin forte QID)
- urgent ophthalmological R/V
Note:
- high risk of retinal tear/detachment
- high risk of glaucoma both acutely and after many years
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4. Vitreous haemorrhage
- must exclude retinal detachment or tear
- urgent ophthalmological opinion
5. Retinal detachment
Management
- rest in bed
- fast
- urgent ophthalmological opinion
6. Traumatic dislocation lens
- may have monocular diplopia
- VA markedly reduced
- slit light examination required
- seek urgent advice
7. Traumatic mydriasis
- due to selective neurapraxia or parasympathetics innervating iris preventing constriction of pupil
- usually temporary but refer to ophthalmologist
8. Traumatic iritis
- red painful eye with photophobia & constricted pupil
- cells may be seen in the AC with slip lamp
- urgent discussion with ophthalmologist
- Rx mydriatic & steroid drops
Reviewer:
Dr Brian Todd, Ophthalmologist, Cairns
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UNILATERAL RED EYE
1. Usually NOT conjunctivitis
2. Don't forget FIGUT
F - foreign body
I - iritis or episcleritis
G - glaucoma
U - ulcer (esp. dendritic)
T - trauma
3. Beware
- contact lens wearers
- photophobia
- decreased visual acuity
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VIRAL CONJUNCTIVITIS
AIMS
With any suspected corneal infection, if ophthalmologist available urgently then do not start topical Tx.
(allows corneal scraping before Tx)
Obtain specialist advice if ophthalmologist not available
(establish Mx plan)
Beware:
- contact lens wearers
- photophobia
- decreased visual acuity
Viral Conjunctivitis:
- adenovirus most common & may be assoc. with preauricular rash
- difficult to distinguish viral from bacterial so treat as for bacterial
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