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Transcript
What?, Why?, and How? to refer
Imran Jawaid
What?, Why? and How? To refer
INTRODUCTION
The day job..
OPTOMETRISTS
OPHTHALMOLOGISTS
Asymptomatic
Symptomatic
No ocular pathology
Ocular pathology
Screening / disease detection
Treatment / disease management
Detect abnormality
Diagnosis and investigation
Spectacles and contact lenses
No refractive correction
Retail pressures (ATV, CR etc.)
No retail pressures
9-5pm
24 hours
Career progression not based on ability to Career progression based on ability to
detect/manage ocular abnormality
manage ocular abnormality
What? Why? and How ?to refer
CHANGING TIMES
“Call to action” – The future...
•
Improve IT links between community optical practices and the rest of the NHS and primary care as
well as improved systems in hospitals
•
Address capacity issues in hospital eye clinics to save patients from unnecessary blindness and
vision impairment
•
Maximise the use of the skills in the eye care pathway by ensuring that patients are treated in the
appropriate place by the appropriate professional at the appropriate time, whether in the
community or in the hospital
•
Procure community schemes at greater scale to reduce procurement and commissioning costs
and direct more resource to clinical care.
•
Improve communication and relationships between the multiple professions through better
commissioning to achieve a more integrated eye care pathway and better patient care
What?, Why?, and How to refer
ARE WE READY FOR THE CHANGE?
Bridging the gap
•
•
•
•
Improve knowledge base
Improve feedback to referring optometrists
Increased exposure to ocular abnormality
Improve understanding of disease
management
• Improve understanding of new treatments
and diagnostic equipment
Common problems
•
•
•
•
Raised IOP
Flashes and floaters
Retinal haemorrhages
Red eye
Elevated IOPs
22T29
History
Asymptomatic?
Angle closure sxs?
(acute/intermittent)
Photophobia?
Visual change?
Previous Trauma?
Medications?
(Steroid/Topiramate)
Ocular treatments
(Laser/Buckle)
Ocular History (Ischaemic
retina)
Pressure..
• History – Symptomatic vs Asymptomatic
• Anterior Segment signs
– Red eye
– KS, KPs and corneal pathology
– AC activity and depth
– Iris atrophy / TIDs / NVI
– Significant cataract
Pressure..
• Gonioscopy
• www.gonioscopy.org
• Redmond-Smith Index
• Van Herrick
Flashing lights and floaters
Flashing lights and floaters...
Flashing lights and floaters...
• History
– Myopia
– Family history
– Visual field defect
– Fellow eye status
• Age
– 6% under 50, 53% over 50, 67% over 65
Examination
•
•
•
•
IOP
AC activity
Vitreous – tobacco dust?, RBC?, vitritis?
Fundus
– Weiss ring
– Vitreous or pre-retinal hge
– Peripheral retina
• Tear/break +/- SRF
• Peripheral degeneration - Lattice
Breaks..
Retinal Haemorrhage
• Anatomy
– Inner 2/3 - CRA
– Outer 1/3 - Choroidal circulation
– CRA divides into superior and inferior branches which
each divide into nasal and temporal branches
– Functionally these are end-arteries
– Central foveal avascular zone contains outer retinal
layers only. Blood supply to this area is derived from
the underlying choroidal circulation.
– Post arteriole retinal capillaries - NFL
– Pre-venular capillaries - INL
Pre-retinal haemorrhage...
Subhyaloid haemorrhages are found between the inner limiting membrane and
the posterior hyaloid face. A pre-retinal haemorrhage is located between the
inner limiting membrane and nerve fibre layer. Both bleeds mask the underlying
vessels
Flame haemorrhage
Hypertensive retinopathy, vein occlusion, AION, disc swelling amongst
others
Recording blood pressure is essential
Marker for the site of future nerve fibre and corresponding visual field
loss
Location should be accurately documented and further investigations
performed
Pale centred linear haemorrhage
Conditions in which Roth spots
are observed
* subacute bacterial
endocarditis
* leukaemias
* anaemia
* anoxia
* carbon monoxide poisoning
* hypertensive retinopathy
* pre-eclampsia
* diabetic retinopathy
* neonatal birth trauma
* shaken baby syndrome
Dot and blot..
Compact middle layers of the retina give rise to the dot and blot-like
appearance of these haemorrhages
Often there is associated oedema and if the macula is involved may give rise
to diminished acuity.
Blot haemorrhages are often larger and darker.
Alert the examiner to search for other features of ocular ischaemia –namely
venous changes, cotton wool spots and neovascularisation.
Sub-retinal Haemorrhage
Between neuro-sensory retina and RPE. They are dark in colour and the
retinal vasculature is clearly visible above
Bleed can be large in area and variable in shape
Sub-RPE bleeds, (between RPE and Bruch’s membrane of the choroid),
have a more confined arrangement as there are tight junctions between
RPE cells
Commonest cause is choroidal neovascularisation
Other causes include trauma, tumours and retinal angiomas
Red eye
• History
– Pain
• FB sensation/ache/ deep pain
– Photophobia
– V/A
– Lacrimation / discharge
– Associated symptoms
• Nausea and vomiting/ frontal headache
– C/L wear
Examination
• Pattern of redness
– Diffuse and superficial
– Diffuse and deep
– Circum-corneal
– Sectoral
• Reduced vision
• Pupils
• NaFl
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Subconjunctival haemorrhage
Management
BP
Reassure
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Conjunctivitis- bacterial/viral
Management
Strict hygiene
Cool compress
Lubricants +/- CPL
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Herpetic Keratitis
Management
Refer
Start oc. Aciclovir 5 x daily if confident
DO NOT GIVE STEROIDS
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Contact lens-related keratitis
Management
Stop C/L wear
Hourly g. levofloxacin
REFER
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Episcleritis
Scleritis
Pain
Photophobia
V/A
Discharge
Assoc. Sxs.
C/L wear
Acute anterior uveitis
Management
Refer to eye casualty same or next day
How to refer
•
•
•
•
S Situation:
Identify yourself the site/unit you are calling from
Identify the patient by name and the reason for your report
Describe your concern
•
•
•
B Background:
Give the patient's reason for attendance
Explain significant medical/ocular history
•
•
A Assessment:
Clinical impressions, concerns
•
•
•
R Recommendation:
Explain what you need - be specific about request and time frame
Make suggestions
Clarify expectations
What?, why? and how to refer
THANK YOU
QUESTIONS?