GP Eye Health Network: Ophthalmic emergencies, Mr K Lett Eye... · Web viewOrbital cellulitis and...

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TITLE: Presentation 7 Mr K LettDATE: 21st February 2017NUMBER OF SPEAKERS: 1 Numbers SpeakersTRANSCRIPT STYLE: Intelligent VerbatimFILE DURATION: 26 Minutes 31 SecTRANSCRIPTIONIST: Marg Searing

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GP Eye Health Network: Ophthalmic emergencies, Mr K Lett

KL: Thanks very much. Thank you for having me to speak. I’ve got quite a lot of ground to cover so, I’ll whip through it fairly quickly. I’ll leave … try and leave some time at the end for some questions. But if there’s anything burning that won’t wait then stick your hand up and I’ll try and answer as we go along.

I’m a Consultant Ophthalmologist at the Birmingham Midland Eye Centre. I’m also, a Vitreo-retinal Surgeon and also, I’m Head of Accident Emergency, well Eye Casualty there.

I don’t have a superhero costume but when I get changed into my blues I end up looking like that.

At the Eye Centre, we have a pretty busy Eye Casualty. We’re the only Eye Casualty for all of Birmingham so you can imagine that we’re pretty snowed under most of the time. As, such, we have to be quite strict about what we see as an emergency within four hours and what we then move in to our urgent care slots.

So, everyone who pitches is triaged by one of our Senior Nurses and they’re categorised according, to a WRAG system which is fairly, standardised. Anyone who is deemed to be, in need of attention within four hours is put through to Eye Casualty. Anyone who we think can probably be seen with 74 hours is given an urgent care slot and these are booked slots in what is currently called the Urgent Care Clinic. And then the completely non-urgent stuff we will try and send back to either yourselves or to local optometrists for either management there or for a routine referral in to our clinic system.

I shall go through some fairly, obvious, examples of what’s really, urgent and then some examples of what is less so. So, looking at this list, I think most of that would be fairly, beyond contention. Anyone with a penetrating eye injury or globe rupture due to blunt trauma. Anyone whose got an intraocular infection following eye surgery is going to be seen very quickly. People who have got very nasty chemical injuries are also pushed right to the front of the queue. A couple of other things as well. Orbital cellulitis and giant cell arthritis as well, particularly with visual symptoms. Really, if they don’t have visual symptoms but they do


have giant cell arthritis they shouldn’t be in our Eye Casual system, they should be put through to the general physicians. I’ll touch a bit on that later on. And anyone who has had sudden loss of vision within the last six hours. Again, we’ll expand on that later.

Other things that do need to be seen within four hours but don’t get pushed right to the front of the queue include painless … sorry, painful red eye with visual loss. People who have got detachments, they tend to come in from optometrists or from other eye units. And corneal ulcers, particularly in people who have got a history of contact lens wear because they tend to be very nasty ulcers.

A couple of other things, people who have got a history of corneal graft who we think might be rejecting and also painful diplopia.

Things that aren’t really, quite so, urgent, this is where things … this is where you get in to sort of a grey area. But the things I certainly, consider to be less urgent, include: floaters and flashes without any loss of vision or without a shadow in the field of vision; a painless red eye or a red eye without any visual loss; retinal vein occlusions; and diabetic retinopathy with vitreous haemorrhage. I have a colleague in the back who may disagree with something, but he’s managing to button his lip so far. And, also, acute wet macular degeneration.

There are fast track clinics for some of these and I’ll touch on them as we go along.

And things that we really, don’t particularly need to see in our department at all, include infectious conjunctivitis, bacterial and viral, you know I think that you are probably likely to be quite comfortable in managing these patients yourselves. Allergic conjunctivitis, blepharitis, lids, lumps and bumps and dry eyes. So, between you and the community optometrists I think that you can look after these patients yourself without recourse to needing the Eye Centre or wherever your local eye unit may be.

And these are the things which by and large, don’t come to Eye Casualty nowadays but we still get the occasional ones slipping through. So, cataracts, people who have got months and months, worth of symptoms. People who have got chronic conditions such as glaucoma or ocular hypertension. Chronic watery eyes which in turn are often associated with ectropion and entropion and none of these things are things, that are going to managed and acutely treated in Eye Casualty.


So, I’ll just touch on a few of the things that we do expect to see. And I also, appreciate that you, yourselves are not necessarily going to see all these things in practice because a lot of these patients will just present themselves to us straightway and that’s absolutely, appropriate.

Acid burns, whether it’s chemical or thermal, corneal abrasions, skin lacerations, foreign bodies and various types of trauma.

So, this a … this is the sequel of a nasty chemical injury and you can see here this is residual epithelium. The rest of this is where the epithelium has all been sloughed off after a chemical injury. There’s already corneal oedema here. Things of note. This part of the eye is looking suspiciously white. And that’s because the blood vessels there have all been knocked out by the severity of the injury.

And one of the first things that we want to ascertain is whether, or not the chemical, the injurious chemical was acid or alkali. And there’s a very good reason for that even though the treatment is the same initially. And that is acid … sorry, acid injuries tend not to be as nasty as alkaline injuries. And the reason for that is because acid injuries, acids coagulate the tissues in front of them. And by coagulating those tissues they cause a barrier to their own progression and the difference between that and alkali injury is that an alkaline will saponify the lipid bilayer of the membrane so it melts everything in front of it. And so, nothing is going to stop it from progressing. So, worst case scenario with a very, very bad, untreated alkali injury you can have this alkali melt its way, all the way from the front of the eye, through to the back.

There is one exception with the acids and that’s hydrofluoric acid. That’s the only one that behaves like an alkali. That said, as I say, we do treat them equally seriously in the first instance and the treatment is the same which is copious irrigation with saline to normalise the pH of the eye. And these patients they get put right at the front of the queue. The potted history, what went in, it’s some sort of chemical. Immediate pH check, immediate irrigation. We worry about the rest of the history later on.

The worst-case scenario, this can cause limbal stem cell failure. So, the stem cells that live on the limbus here, if they’re permanently destroyed then these patients end up with permanent persistence epithelial defects, corneal scarring and they end up needing grafting including limbal stem cell grafting. And this is why this area here is so worrying


because this marble white effect here is a good indication there’s serious limbal damage.

Corneal abrasions. A lot of these people come our way because we’re often the easiest people to get to but actually, in the vast majority of cases, the history tells you that this injury is really quite trivial. So, by far and away, the commonest things that we hear about are the baby’s finger, that’s one. And also, gardening is an extreme sport so the number of people that [laughing] come in and say, well I bent down and impaled myself on a yucca plant or some such is quite remarkable. So, I tell my wife that’s why I don’t do any gardening.

[laughing]

These patients as I say, typically the history is quite trivial and you have the tools, at least I hope you have the tools, to make the diagnosis yourselves. So, a drop of Fluorescein and use the red free filter on your direct ophthalmoscopes and it should be quite evident. And these patients simply need some chloramphenicol in the vast, majority of cases. There will be those cases which are penetrating injuries but you can typically tell from both the history and from even a cursory examination that it’s a nasty one.

The jury is still out. Personally, I don’t but there are still plenty of practitioners who do. The reason that I don’t is because I don’t actually, believe that it makes any difference to the speed of recovery. And what I worry about slightly more, is that patients may be able to open their eyes underneath the pad and if they do manage to do that then, they’ve got the pad straight up, directly against their cornea which is going to exacerbate the situation. So, personally, I don’t.

Foreign bodies, again, you should be able to tell from the history whether it’s a nasty one or not. And, certainly, in days gone by when there was a lot more industry in the West Midlands there were a lot more higher velocity metallic foreign bodies. But that’s far less common nowadays and so the prevalence of incidence of penetrating injuries has commensurately gone down.

Now, some places have a PEARS or a MECS system PEARS being a primary eye assessment and referral system operated by community optometrists and MECS stands for Minor Eye Conditions Service. And they’re both run by local optometrists. In Birmingham, we don’t really, have that fully up and running yet, although it’s threatening to be so. I


think it’s safe to say at the moment that again, the jury is out until we actually, have some feedback as to whether or not this system genuinely results in a reduction of patients coming to Eye Casualty. I think it’s particularly good in more rural settings where for … I know of a service in rural Scotland where patients would have otherwise, have, to travel 80 or so miles to get to their nearest eye unit. And I think in those cases these PEARS systems are absolutely, indispensable. But in an urban setting, not so sure yet. So, watch this space.

What I would say with these foreign bodies is that, it is well worth, in fact, it is essential that one checks underneath the eyelid as well. And inverting the eyelid is actually, not very difficult, at all. I’m sure you can see videos of it on YouTube or iTube. It’s actually, a very simple thing. But if you miss a subtarsal foreign body, that’s a sort of, you’re getting on to the area of negligence there. If someway there’s something underneath the eyelid because the reason they’re vertical is cos, every time the patient blinks they’re causing a further scratch. If you’re happy taking them out yourself, great. If not, then of course, we’ll do it for you.

Subconjunctival haemorrhage, very, very common and in ninety-nine point something of cases is completely, I won’t say trivial, but it’s completely self-limiting and no treatment is needed. Obviously, if these … if you have a patient who has got a multiple repeated subconj haemorrhages you might want to look at their clotting and so forth. But in the vast, majority of cases, they’re spontaneous or they’re caused by the most trivial of trauma and they certainly do become more common in the older population as well. We don’t treat these. We don’t do anything with them. I have yet to see, in my nearly 20 years of practice a superficial subconj haemorrhage which was associated with an intraocular bleed.

Blowout fracture on the other hand, is quite serious and the damage from these blunt injuries can go back a lot further than one might initially suspect. So, these patients need a full front to back assessment because not only can they have problems with their ocular surface but if it’s a really, nasty injury then they can also have damage to their optic nerve as the shockwave passes through the orbit. So, we obviously, do need to see these patients. And certainly, if there’s any evidence of restriction of eye movement then they’re going to need fairly, extensive management.

What I would say is, that even if these patients do have signs of tissue entrapment as you can see in this case, where this patient’s trying to


look up and you can see that their left eye is still fixed in the primary position, the surgery is not actually, performed on an emergency basis. This is by the way, two different patients, not one very, very unlucky one. And the … sorry, the orbital surgeons actually, don’t get in to a panic over this and they normally have surgery within four weeks. So, it’s not as though these patients have to go to theatre the same night, the following morning or anything like that. There’s plenty of time to work on these patients but we do need to see them.

Cornea. This probably amounts for … this is one of the biggest percentages of patients coming in to an Eye Casualty Unit. And there are lots of things that can affect the cornea, but then, I’ll just briefly go through the ones which I think are most relevant to you.

So, dry eyes, you’re going to know the history. You know patients that typically come in saying I’ve got gritty dry eyes and sometimes I get a lot of reflex watering. So, you’ve got a pretty, good idea. Things to look out for, in particular, are blepharitis. So, if you see lots of debris encrusting on the roots of the eye lashes, that’s anterior blepharitis. If you have a good look at the lid margin it looks a bit bobbly and uneven, that’s posterior blepharitis. Both of those are far more associated with dry eye syndrome than primary tear film deficiency which is actually, very, very unusual. And if that is the case, then treatment really, should be primarily directed at the underlying cause.

So, lid hygiene for anterior blepharitis, hot compresses, lid massage for posterior blepharitis. The lubricants that you prescribe are really for symptomatic relief. You know, they’re not going to address the underlying problem. And unless you do address the underlying problem, you’re going to be prescribing lubricants for these patients for the rest of their lives. And I’m sure that you don’t want to do that.

We don’t need to see these patients unless you’re really, not able to get on top of it. And you know, things where we might get interested are, if you see lots of staining of the corneal epithelium. This is clearly, a very, very dry eye. And in these cases, we might need to get involved. But in the vast, majority of cases put them on some lubricants, address their blepharitis. That’s normally, going to make life much more comfortable for them.

There are lots of different treatments available on the market now which are not approved by NICE and in my opinion are probably unlikely ever


to be so, such as, Lipiflow and all these, sort of fancy ways of applying heat and pressure. But heat and pressure is what these patients need.

Recurrent corneal erosions are very, very common. And …

MS: Do you want the lights on or off?KL: I don’t really, mind. It’s up to the audience I suppose. Is that better? I’m sure it is. Yeah. Thank you.

Again, the history will tell you everything because almost without fail, if you dig deep enough and far back enough, the patient will admit to an index injury with that yucca plant or with that fingernail. And it could be 20 years ago, but there will almost, always be this history.

And what happens here is that, although the epithelial defect heals over initially, it never really, beds down on to the underlying stroma properly. The hemidesmosomes don’t link up properly and so this area of epithelium is always a little bit loose. And then what happens is, when you’re sleeping, you don’t blink as much so the inside … your eyes dry out slightly and they become slightly adherent to the inside of your eyelid. And then when you wake up and you’ve got this, loose epithelium slightly adherent to the inside of your eyelid, it rips it off. And so, again, these patients will almost without fail tell you that it’s this pain, this excruciating pain on waking.

And what these patients need apart from some lubrication during the day time, what they really, need is a good three months’ worth of copious night time lubrication. And what they need at night time is something a bit greasier. So, if you give them sort of Carmellose or Hypromellose, that’s not gonna stick around for long enough. What they need is something greasy. So, something like Simple eye ointment or Lacri-Lube. Something which contains a bit of paraffin. And, although it’s a bit of a pain because it makes your vision very blurry, if they put it in last thing at night it shouldn’t really, be a problem. And that gives them enough lubrication overnight to allow, hopefully, allow the epithelium to really, settle down properly. And again, we don’t need to see these patients unless they’re, really, really, not responding.

So, we’re on to the genuine nasty stuff. Corneal ulcers are, you know potentially problematic in any case but more so than any other case, are those in patients with a history of contact lens wear. Because contact lens related ulcers just tend to be much nastier. The bugs are nastier. The treatment is more challenging. And the outcomes are often worse


as well. So, if anyone have a history of corneal lens … sorry, contact lens wear and they come up with a corneal ulcer there is no question that we do need to see these patients. Worst case scenario, we admit some of these and they stay with us for days on end if not sometimes, occasionally weeks. But worst case scenario, with a bad corneal ulcer or a recalcitrant one is that they perforate their cornea and then you’ve got an open eye and these patients are then potentially looking at corneal grafting.

There is a big difference between this, which is a nasty corneal ulcer which is rounder, central, typically in a younger patient, from marginal keratitis which is typically going to be in an older population and it’s going to be a small linear little opacity down here very near to the limbus or near to the margin, hence its name.

And there is, the other good way of telling the difference apart from the clinical appearance is the pain score that the patient gives you. So, marginal keratitis is normally described as uncomfortable. Okay, it’s actually not very rare … not very commonly described as painful. This is painful. Marginal keratitis is, to all intents and purposes, a self-limiting condition. We do give them some mild steroid and some antibiotic but actually, it will often settle down on its own.

You are bound to see a lot of these. And I think people probably get a little bit more excited about these and worried about them than is strictly necessary. It’s a self-limiting conditioning again. This is the same thing that causes a cold sore. So, it is self-limiting whether you treat it or not. That said, when we see it we do treat it and topical antivirals are the treatment of choice. There are sometimes some supply problems with Acycloir and there’s sometimes a supply problem with Valgancyclovir but by and large they’re not normally out of circulation at the same time.

These patients don’t need to be seen super urgently, they don’t need to be seen in the middle of the night or anything like that and personally, I send them through to our urgent care clinic. Also, again, personally, I don’t follow these patients up unless they’ve got a history of ulcers which won’t settled down or they’ve got a history of extensive corneal scarring. But by and large they will behave very nicely.

I certainly don’t need to say what this is because I’m sure you see far more of it than we do. But from an eye point of view, again I think people probably get more worried about eye involvement than is strictly necessary.


The first thing to remember is that not everyone with Shingles gets eye involvement and the tell-tale thing which is sort of an indication they are possible going to get it is Hutchinson’s sign. So, if they have involvement of the nasociliary there’s about 70% chance that there will be ocular involvement.

Now that ocular involvement in, itself doesn’t always need treatment either. And although people can develop dendritic type ulcers on their corneas, they’re called … in these cases they are actually, typically called microdendrites, those strictly don’t actually, need to be treated. And it’s really, very common to get a bit of a red eye with this because you’ve got all these vesicles near to the lid and you get the inflammatory response. But actually, most eye involved with Shingles doesn’t necessarily need to be treated.

Conjunctiva. I’ll skip through this very quickly because I’m sure you’ve got lots of experience of seeing this. But, bacterial conjunctivitis, you’re going to see, you know, bits of mucopurulent discharge. It’s self-limiting whether you treat it or not. If you do want to treat it then you can pack them off with some chloramphenicol. We don’t need to see them. You don’t need to follow them up.

Viral conjunctivitis, you’re gonna get the watery discharge although the patients will often admit that they’re eye is sticky in the morning but it’s not sticky throughout the day. It’s not pushing out pus throughout the day. And that’s the big difference in the symptoms. And if you look at … if you pull their eyelid down and you look at the conjunctiva, you’ll see these follicles. They’re like little grains of rice shaped things, as though they’re grains of rice underneath the conjunctiva and there’s no treatment for this anyway is there. So, you can pack them off. The only exception is if they’ve got obvious corneal involvement in which case they may sometimes require a short course of steroids and we obviously, then do need to get involved.

But by and large, it’s self-limiting. There’s nothing you can do about it. Tell them to sit it out and make sure, the most important thing really, is to make sure that they are maintaining good hand hygiene. They’re not sharing flannels and bath towels t home with the rest of their family because they do that, surprise, surprise, it’s going to go through the entire family like a dose of salts.


Allergic conjunctivitis. It astonishes me, how every summer or thereabouts, I get a handful, well not a handful but an absolute bus load of patients coming into Eye Cas and saying, do you know what, it’s really, odd that every year in the summer time, I get this problem and I’ve no idea what it is. Well you’ve got it happening, no, really, yeah, okay [laughing]. History of hayfever? Oh yes, yeah, yeah. And you still have no idea what it is? Okay. So, you know, that’s the most common thing but there are obviously, other triggers. Other triggers are available, but you know it’s very easily treated but … in the main.

Episcleritis and scleritis, your probably not going to see so many but it’s worthwhile knowing the difference and how easy it is in general to tell between the two.

Episcleritis is a self-limiting condition again. But if you want to give them something to help them along the way then, actually, it’s probably better to pack them off to the local supermarket and get them to buy generic over the counter ibuprofen. That works very nicely, in both, the patient psychologically becomes steroid dependent because they think that there’s no other … that there’s no alternative treatment for it. So, I try and avoid that. Having said that, there are plenty of cases out there which don’t respond to non-steroidals and we will give them steroids.

And I … I’m sure I … I’m sure you can appreciate that there’s quite a difference between the previous slide and this one. This is scleritis and this really is actually, very serious and nasty. And it’s an entirely different level of pain. So, this is very high on the pain scale. Patients often can’t sleep at night because of the pain and it’s a much angrier red. Okay. There’s a very strong association with autoimmune and connective tissue disease and so we certainly do need to see these patients.

Scleritis is potentially a sight threatening condition. So, you know, although I’ve spent a lot of time saying try not to refer this in, when you see scleritis we definitely, need to see these patients. And a lot of these patients do end up being admitted and thoroughly, thoroughly investigated.

Lids. You’ll see a lot of this as well. And, you know, most of this stuff is not terribly serious.

Blepharitis I’ve already talked about. So, these are the bits of debris on the … collarettes around the roots of the eyelashes.


So, that’s anterior blepharitis and for that, lid hygiene is the key. And the reason these patients get grittiness is because this debris drops on to the surface of the eye.

This is posterior blepharitis. So, these are the outflow dots of the meibomian glands on the lid margin. And you can see how they’re all clogged up with gunk. That’s a technical term. [laughing] And, what happens here is that they prevent the oils which should contribute to the tear film from reaching the surface of the eye. So, that’s why these patients get dry eye symptoms.

You can see here this patient also has anterior blepharitis sign as well and it’s very, very common to have both anterior and posterior at the same time.

So, for these, hot compresses, wooden spoon hot compresses. Typically, very, very effective. They may be a bit of a pain to have to apply on a, daily basis but they do work. And in both these cases, as I say, you can give them topical lubricants to help them along the way.

Chalazia, we’re not gonna do anything about this in eye casualty except in the most extreme circumstances. And if you see them in their non-infectious state like this, then we simply need a routine referral for incision and curettage. If they become infected, then you can give them oral antibiotics. There’s not really, a huge amount of benefit in giving them topical antibiotics. It doesn’t touch it. But what they need is oral. If it’s really, really, nasty then occasionally we might do an acute incision and drainage. And I’ve done one, in again, nearly 20 years. But by and large, we don’t do them in the acute phase.

We see a lot of this, you see a lot of this. And again, there is nothing that is going to be done about it on an acute footing. The main … the commonest cause of both of, these is the same thing, actually. it’s laxity of the horizontal lid tendons and the difference between whether, or not that horizontal laxity turns in to an ectropion like this or an entropion like this, is purely to do with whether or, not the inferior lid retractors ride over or ride under that laxity.

But the treatment is the same from our point of view. In the vast, majority of cases something called a lateral tarsal strip which is a small operation which also doubles up as a face lift, actually. So, some patients like to have both eyes done at the same time. And what you do


is, you disconnect the lateral canthal tendon from the orbital rim there. You shorten it by just simply snipping a bit off. You tidy up the skin around it. And reattach, you re-suture the end of the tendon to the orbital rim again. And that gets rid of the laxity and problem solved.

But in the interim, before they get to that then what you can advise the patient to do is take some tape and tape the lid. But you don’t tape the lid down in that case and you don’t tape the lid up in that case. What you do, is you fashion a strip of tape and you start about there, and you make the strip pass horizontally and then slightly upwards at the edge of the socket. And what that does, is that tightens the lid artificially. And it will work with both things. Okay. So, that’s the way of … that’s how you deal with this in the interim period between them coming to you and them having surgery with us.

And those patients, again, they need lubrication. In the case of ectropions because they get incomplete lid closure. So, they don’t cover their ocular surface with tears very effectively so, they need lubrication. And in the case of entropion they get irritation from the eyelashes and they get little microabrasions on the cornea, so, again they need lubrication.

Preseptal cellulitis, the main thing that people worry about of course is, is it preseptal cellulitis or is it orbital cellulitis. And I would say, that by and large, the easiest way of deciding is looking at the general state of your patient. If … preseptal cellulitis for starts is by far and away, more common but also, it’s more common … it’s the commonest one of the two in children. So, if that child is bouncing around your waiting room and in your consulting room and they’re happy and just being a general pain, then it’s almost certainly, going to be preseptal cellulities yeah.

Other things, they’re not going to be pyrexial, they won’t have any orbital signs so there’s no proptosis. There’s no restriction of eye movements. There’s no afferent pupillary defect. And they’re vision isn’t affected. Yeah, so these cases, you simply treat with oral antibiotics. And obviously, there’s the caveat, if you’re really, not sure then you know, we’ll have a look at them as well, obviously, or the paediatricians will. I say that, because there are no paediatricians here. So, in fact, send them all to paeds and then the can send [laughing] them on to us if they can’t make up their mind, in fact, do that please.

This on the other hand, really, is nasty. This is orbital cellulitis and I haven’t shown you the entire face but there are some give away clues


here. For starters, the fact that the patient who is … the person who has taken the picture or maybe the person who examined the patient is having to hold the lids open to get a view of the eye. And that’s because the lids are very tense and they’re closed. And that’s because they’re very swollen, they’re infected. Also, then you’ve got lots of chemosis. This is swelling of the conjunctiva and you don’t get that in preseptal cellulitis very often.

So, this is a hot orbit. And I’m not sure whether this patient’s dilated or not. But just for the sake of this talk, I’ll say that this is a very gross afferent pupillary defect. This is a dilated pupil which means that the optic nerve is compromised okay. And if you look at the generalised colouration of the skin there, it’s all mottled and dark. Now, I’m going to hesitate to use this word but I’m gonna do it anyway. And with your mind’s eye, you could almost call that colouration ‘dusky’. And if its dusky, if anyone uses the word dusky to me in relation to this, the panic sets in a bit. Because, certainly, in ophthalmology circles or plastic surgery circles, dusky, suddenly starts sounding a bit like necrotising fasciitis. Okay, so, if it is that then obviously, this is really, very serious.

These patients do need admission. They need intravenous antibiotics and they need extremely close monitoring in case they need large amounts of debridement. So, this really, is an emergency. But these patients are very, very different to those kids bouncing around your waiting room, okay. They’re moribund. They are grossly, grossly, unwell. They’re pyrexial. This patient is not going to have much in the way of eye movement because he’s got a very tight orbit. You can tell.

Neuro-ophthalmology, I’m going to very quickly run through it cos I’m not a neuro-ophthalmologist but there are a few classic things that you will undoubtedly be aware that you need to be more, or less worried about.

The classic on really, is a painful third. The problem with … and you know, teaching from medical school onwards, all through back in to the mist of time says, a painful third is a neuro-surgical emergency. Because painful means, probably posterior communicating artery aneurism that’s about to go pop. Actually, the vast majority of painful thirds are in diabetics and they’re nothing of the sort.

But you don’t know that until you’ve scanned them and ruled it out. So, no matter what you think, you know whether you think, oh that’s probably a diabetic one in a patient who is diabetic and who has got terribly bad HBA1Cs and has done for the past 20 years. You just don’t know and


you probably can’t take the risk. So, these patients need to be in. They need to be scanned and we need to ... we need to get the neurosurgeons involved should the need arise. So, that’s one of the classic teachings which is not entirely reliable.

Associated headache, you’ve got to think of giatal arthritis again. Because GCA is the great mimicker. It, sort of, crops up as all sorts of different present … with all sorts of different presentations. So, particularly with sixth nerve palsy, our trainees are all told, you have, to look for the signs of GCA.

But the reality is, in the vast, majority of cases it’s going to be your elderly population. It’s going to be a microvascular nerve palsy which is going to be treated pretty, conservatively.

Disc swelling is probably the flavour of the month. I’m sure that you’ve all heard about the Honey Rose case. Of the optometrist who was recently found guilty of manslaughter. And it’s no coincidence that since that ruling came out we in Eye Casualty have been absolutely inundated with an increase of query swollen discs. And so, we have, to find a way around this because unsurprisingly, the majority of cases are nothing to worry about at all.

There are lots of reasons why people have apparently swollen discs. And in the vast, majority of cases, it’s physiological. It’s just how their discs look. If they, also, happen to be long-sighted that’s another good reason for them to have swollen discs. And there are all these changes which the text books will tell you to look for. Okay, and with the equipment that you have, it’s not that easy. You know, I use a direct ophthalmoscope probably about once every two or three years if I can’t avoid it. And that’s the equipment that you have and I fully appreciate it that it’s pretty, difficult to examine with one of those. But those are the things that you’re always told to look for.

The thing that again, either sets the alarm bells ringing in me, or makes me think don’t worry about it too much is this. Does the patient have visual symptoms? Because if they do, then you start to think, okay, we need to be … need to be a bit careful with this and start digging around properly. But if they’re completely asymptomatic, if they don’t have visual symptoms, if they don’t have headache and they’re fine, there’s every likelihood that they are fine.


Not all disc swelling is due to a tumour in the brain. And you know with a lot of patients floating around with MS, we and probably you as well see a lot of optic neuritis. And there are, some sort of … there’s a classical picture with this. And the classical picture is that its unilateral. It’s in a patient who is in the right age range to have demyelinating disease and typically, they describe, two weeks’ worth of deterioration, two weeks’ worth of a trough and then over the next two weeks’ things start to pick up again and most of them will recover most of their function. Not 100% but sort of in the 90, 95 to 98/99 per cent recovery of function.

There are a few other little tips and tricks to ask for. So, if they’ve got … oops! Sorry. If they’ve got Uhthoff’s phenomenon, that’s always a good one in the history. That is, you ask them if their blurring of vision gets worse if they raise their core temperatures. So, bath or exercise okay. But we will be seeing these patients. We don’t treat these patients in the vast, majority of cases.

Papilledema, more of the same. Giant-cell arteritis, you know all the symptoms. Please, if they don’t have visual symptoms don’t send them to us in the first place okay. We’re not the right people if they don’t have visual symptoms. Send them on to their physicians or rheumatologists. We’ll get involved alter on if necessary.

Glaucoma, I’ll only very quickly talk about. Acute angle, these patients, elderly often hypertrophic. They come in to us from about midday onwards. The reason for that is cos they’re pressure hasn’t hit that level until around 10 or 11 in the morning, okay. And obviously, we need to see these patients. Lots of treatment, surgical, laser, medical.

And I’ll pretty, much bypass this because you don’t have the right equipment to look for this stuff. The … if you’re worried about this, you could send these people to the optometrists first who will then, sort of, screen the patient and send them on to us.

For floaters and flashes, posterior vitreous detachment, retinal detachment is actually, pretty, unusual. Vitreous haemorrhage, if they’ve got a history of systemic disease which suggests they would have a vitreous haemorrhage or they’re prone to it, then we can see them as an urgent care patient.

Detachments, obviously, you’re going to send them to us, but they’re probably not going to come to you very often in the first place.


Macular degeneration and venous occlusions. We have rapid access clinics for both, of these. So, strictly speaking, these patients don’t actually, have to come to Eye Casualty at all. You can just let us know about them, send us their details and we will arrange for them to have rapid access clinics. They’re typically seen within a couple of weeks. There are proformas available which you can fill in or you can find on our website. But if you speak to us then we will do what we can. But these patients aren’t going to benefit from being seen in Eye Casualty on the day.

Giant-cell arthritis. All I’ll say with that again, is if you do think … Sorry! Arterial occlusions. If you think about arterial occlusions, again think about Giant-cell arthritis. I’ll bypass that.

The future of Eye Casualty is this. You know this very well. Every year, there’s about a 6 to 9 per cent year on year demand, increase in demand and we have, to cope with it somehow. 30% of our attenders really do need to be seen with four hours. In fact, it’s even less than that probably. So, we have, to make the most of our community optometrists, in some respect. We use a lot of allied professionals at the Eye Centre and we’re going to use more and more of them. But we all need help in managing the increased demand as you do as well.

Thank you very much.

[applause]

END OF TRANSCRIPT


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Transcript of GP Eye Health Network: Ophthalmic emergencies, Mr K Lett Eye... · Web viewOrbital cellulitis and...