Matt Edmunds Clinical Lecturer / Specialty Registrar Academic Unit of Ophthalmology University of...
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Transcript of Matt Edmunds Clinical Lecturer / Specialty Registrar Academic Unit of Ophthalmology University of...
Ophthalmology in Primary Care
Matt EdmundsClinical Lecturer / Specialty RegistrarAcademic Unit of OphthalmologyUniversity of Birmingham
What I have been asked to address (1)
What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?
Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?
What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow morning/clinic? How should we access these/ advice OOH?
What I have been asked to address (2)
The red eye
What to do about dry eyes/ watering eyes/ blepharitis
What to do about floaters and/ or flashes What mistakes do we make in our history-
taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?
Question 1:
What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?
What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?
Ophthalmology in primary care Broad generalisation…….
Most patients will present with ‘red eye’ Significant proportion of red eye can be
managed in primary care▪ Whereas most ‘non-red eye’ pathology is likely to
require secondary care input Limitations
Not much training in eyes▪ Year 4 MBChB at UoB: 5 days ophthalmology▪ Few GP VTS posts in ophthalmology across Midlands
Lack of equipment Pressurised for time
History
Acute or gradual onset? One or both eyes? Is vision affected? Discharge?
Purulent? Watery?
Pain? Sensitivity to light? Contact lens wearer? Previous episodes? Industrial injury? Associated systemic symptoms?
What we would hope for….
Visual acuity (and idea of any recent changes) Pupil reactions Eye movements Gross observations
Lid swelling and discharge / lash crusting Distribution of any redness / obvious eye lesions Corneal staining with fluorescein / FB Comment on anterior chamber / cornea▪ TIP: Ophthalmoscope on +20D
Optic disc / fundus Not easy with ophthalmoscope Please, at least try
Visual acuity testing
Can use book eg BNF/BMJ if snellen chart not available on wards
Snellen charts needed in practice
How to tell a person’s refraction
Hypermetrope (convex)
Myope (concave)
Almost emmetropic
Visual acuity testing
If unable to read top line on Snellen chart:
Visual acuity testing
If unable to read top line on Snellen chart:
Count fingers? (CF)
Visual acuity testing
If unable to read top line on Snellen chart:
Count fingers? (CF)
Hand movements? (HM)
Visual acuity testing
If unable to read top line on Snellen chart:
Count fingers? (CF)
Hand movements? (HM)
Perceive light? (PL)
Visual acuity testing
If unable to read top line on Snellen chart:
Count fingers? (CF)
Hand movements? (HM)
Perceive light? (PL)
No light perception (NLP)
Apologies!
Conjunctiva
Limbus IrisCornea Lower
punctum
Upperpunctum
Caruncle
Over the phone
Temporal Nasal
Superior
Inferior
12
6
9 3
Question 2:
Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?
Dark room Dim ophthalmoscope light Smaller pupil setting Get patient to look into distance ?Pharmacologically dilate pupilsMainly: have low expectations!
Question 3:
What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow
morning/clinic? How should we access these/ advice OOH?
Key things to remember
There may be disparity in sense of urgency
You may get a different response to a referral at different times of the day – appropriate
Please don’t ‘opt out’ of ophthalmology
Please always send a brief referral letter
Guidelines for Referrals Same day
Acute glaucoma Temporal arteritis (with definite ophthalmic symptoms) Painful eye after cataract surgery Painful or red eye after corneal graft Painful or red eye in contact lens wearer Orbital cellulitis Suspected corneal infections
Could wait until next day Uveitis Zoster with eye involvement Scleritis
If not resolving as expected Conjunctivitis Episcleritis
Via out-patient clinic Blepharitis / Dry eye / Chronic grittiness or soreness Entropion Ectropion
I will see overnight…
GCA with eye involvement Temporal pain / jaw claudication / night sweats / weight
loss / transient visual obscurations / visual disturbance CRAO within past 24 hours
Sudden and persistent unilateral painless loss of vision Orbital cellulitis Significant chemical injury Suspected penetrating eye injury / significant
trauma Retrobulbar haemorrhage
Acute glaucoma Suspected endophthalmitis
Painful red eye / reduced vision / recent intra-ocular intervention
Can wait until tomorrow morning…
Suspected retinal tear / detachment Suspected vitreous haemorrhage Suspected optic neuritis (unless GCA) New onset diplopia
Unless 3rd nerve palsy / complex CN palsy
Most trauma Most red eye pathology
BMEC Eye Casualty
Open for walk-in patients 365 days / year No referral necessary
Accept all patients 9am – 7pm Mon-Sat / 9am-6pm Sun and Bank Holidays
Urgent care clinic available via triage nurse Also have acute referral clinics at RHH / SGH
Limited number of clinic slots Accept direct GP referrals
No emergency eye clinic at QEH
OOH
On-call registrar via telephone overnight
Discuss emergency patients
Review patients on eye ward if necessary (Sheldon Block, City Hospital, Dudley Road)
Senior SpR (4th on-call) will review patients in peripheral units if necessary
If in doubt
Contact triage nurse at BMEC Call on-call SpR (2nd or 4th on-call) at
BMEC Send to BMEC eye casualty
With a letter If patient will arrive before closing time
(7pm)
Question 4:
The red eye!
What to do about dry eyes/ watering eyes/ blepharitis
Red Eyes
Up to 80% of eye casualties present with a red eye
Causes of a red eye can be roughly divided into two groups Pain +/- blurring of vision No pain and normal vision
Common pathology is common! Most red eyes are due to conjunctivitis /
blepharitis / dry eye If you can confidently exclude ‘serious’
pathology Oc. Chloramphenicol 1.0% QDS Warm compresses Lid hygiene Lubricants PRN▪ Celluvisc / Optive / Systane / Hyloforte / Xailin
Olapatidine BD (Opatanol) for allergic disease Discuss / refer if not improving / resolving
Pain +/- blurred vision
Important differential diagnoses include: Acute glaucoma Corneal infections Anterior uveitis
(iritis) Scleritis
No pain Differential
diagnoses include: Conjunctivitis Episcleritis Subconjunctival
haemorrhage
Red Eyes
Causes
Eyelids Conjunctivitis
Bacterial Viral Chlamydial Allergic
Keratitis Bacterial (Marginal) Viral
(Episcleritis) / scleritis Acute anterior uveitis
(iritis) Angle closure glaucoma Orbit
Orbital cellulitis Trauma
Subconjunctival haemorrhage
Corneal abrasion Corneal FB Chemical burn
Blepharitis
Chronic inflammation of
the eyelid margins
Causes
Usually Staph aureus or
epidermidis
Associated with skin disease •Acne rosacea•Seborrhoeic dermatitis
Symptoms
Sore
Gritty
Occasionally red eyes
Examination
Hyperaemic lid
margins
Crusts on lashes
Blocked meibomian
gland orifices
Meibomian cysts
Complications
Conjunctivitis
Marginal keratitis
Meibomian cysts
Blepharitis – Treatment Lid hygiene Warm compresses
Gentle expression of lipids with a cotton tipped applicator
Gentle lid cleaning with a solution of sodium bicarbonate
Antibiotic ointment Lubricants Omega-3 Low dose tetracyclines
Antibiotics Lipid soluble Protease inhibitors
StyeInfected hair follicle
ChalazionBlocked meibomian gland
Entropion
Ectropion
In-turning of the lower lid
Out-turning of the lower lid
Herpes zoster ophthalmicusShingles
Conjunctivitis
Bacterial
Viral
Chlamydial
Allergic
Cicatrising
Bacterial conjunctivitis
Causes
Usually staphylococcus, streptococcus or
haemophilus species
Symptoms
Slight discomfort
Red, sticky eye(s)
Visual acuity is not affected although
slight blurring due to purulent exudation, which clears when
discharge is blinked away
Examination
Generalised conjunctival injection
with purulent discharge
lashes may stick together
Bacterial conjunctivitis
Causes
Usually staphylococcus, streptococcus or
haemophilus species
Symptoms
Slight discomfort
Red, sticky eye(s)
Visual acuity is not affected although
slight blurring due to purulent exudation, which clears when
discharge is blinked away
Examination
Generalised conjunctival injection
with purulent discharge
lashes may stick together
Bacterial conjunctivitis
Complications
Usually nil
Treatment
frequent antibiotic drops - instil hourly for 24 hours
then qid for a week
general hygiene by not sharing towels
etc
Viral conjunctivitis
Causes
Usually adenovirus (self-limiting, but can
also affect cornea -
keratoconjunctivitis)
Symptoms
Red, watery eye(s)
Gritty, uncomfortable
feeling
Viral conjunctivitis examination
Vision unaffected unless the cornea is involved
Generalised conjunctival
injection with watery discharge
Follicles (lymphoid
aggregates) in the tarsal conjunctiva
Petechial conjunctival haemorrhag
es
Enlarged pre-
auricular lymph node
Associated URTI
Viral conjunctivitis
Complications
Highly contagious• Risk of epidemics• Nosocomial
transfer
May last several weeks
Small corneal opacities leading to
photophobia and reduced
vision
Treatment
Nil
Antibiotic drops to prevent secondary bacterial infection
General hygiene by not sharing towels
etc
Chlamydial conjunctivitis
“Unilateral red eye in a young male”
Red, watery eye(s)
Vision unaffected
Gritty, foreign body
sensationChronic
Follicular reaction
Usually young adults
Sexually acquired
Requires systemic
antibiotics
Allergic conjunctivitis
Acute onset Red, itchy eye(s)
Chemosis (conjunctival
oedema)Vision unaffected
Type 1 hypersensitivity reaction•Seasonal•Perennial
Often settles spontaneously
Oral antihistamines
Sodium cromoglycate /
Olapatidine
Keratitis
Bacterial
ViralAutoimmune
Fungal
Bacterial keratitisBacterial infection of the cornea
An ophthalmic emergency
Causes
Large range of gram
positive or negative
organisms
Predisposing factors include
Corneal abrasion
Contact lenses
(usually soft
extended wear)
Topical steroids
Corneal anaesthesia
(e.g. previous herpes zoster ophthalmicus
)
Clinical Features
Symptoms
Red, sticky eye
Pain
Reduced vision
Photophobia
Examination
Conjunctival injection with
purulent discharge
Corneal abscess
(yellow/white area on cornea)
May be activity (cells)
in anterior chamber
Clinical Features
Clinical Features
Complications
Severe sight-threatening intraocular infection
(endophthalmitis)
Corneal perforation
Loss of eye
Treatment
Admit•Scrape cornea•Gram stain•Culture and sensitivities
Bacterial keratitis treatment
Sterilisation phase• Hourly antibiotics (usually
monotherapy with a fluroquinolone) day and night for 2 days
• Hourly antibiotics by day for three days
• Cycloplegics• Intraocular hypotensives• Sub-conjunctival injections to be
AVOIDED
Healing phase• Healing retarded in persistent
inflammation• Judicious use of topical
glucocorticoids• Treat ocular surface disease (dye eye,
entropions, blepharitis)
Causes
Herpes simplex type I
(commonest)
Symptoms
Reduced vision - frequently
Unilateral red eye
Pain
Photophobia
Examination
Conjunctival injection
Classical branching dendritic
(epithelial) ulcer staining with fluorescein
Reduced corneal sensation
Complications
Corneal scarring
May affect deeper corneal
layers e.g. stroma (disciform
keratitis)
Corneal perforation
Viral keratitisViral infection of the cornea
Herpes simplex keratitis
Viral keratitis
Complications
DO NOT USE
STEROIDS
Treatment
• Secondary bacterial infection
• Ulcer may recur
• Geographical ulceration
• Antiviral ointment (e.g. aciclovir) tapering over a few weeks
• Dilate pupil
Scleritis
Idiopathic
Infective
Systemic
disease
Scleritis
Anterior scleritis is sub-divided into • Diffuse • Nodular • Necrotising
Anterior scleritis is commonest but posterior
involvement also occurs Inflammation of the
outer (white) coat of the eye and can be a severe
destructive, sight-threatening disease
Scleritis
Causes
Majority idiopathic
40% associated with a connective tissue or vasculitic
disease, commonest being
rheumatoid arthritis
Infections• Varicella Zoster• Acanthamoeba• Bacterial endotoxins
Symptoms
Pain (may be so severe that it
wakes the patient at night)
Red eye(s)
May be recurrent
Pain on EOM
Examination
Deep red colouration of anterior sclera - may be diffuse or
localised
Visual acuity may be normal
Scleral thinning associated with
bluish/black discolouration from
underlying uveal tissue
Treatment
Systemic corticosteroids/pu
lsed immunosuppressi
on for severe cases
Topical steroids as supplementary
therapy
Oral NSAIDs for mild cases
Complications
Visual loss
Scleral thinning
Perforation of the globe
Optic disc and
macular oedema
Intraocular inflamation
Uveitis
Endophthalmitis (infection
inside the eye)
Acute anterior uveitis (iritis)Inflammation of the iris
Uveitis cannot be accurately diagnosed without the aid of a slit-
lampCauses• Majority unknown, occurs
usually in 20-50 year age group
• May be associated with a systemic disease e.g HLA-B27, sarcoidosis
• May be associated with an infection e.g. herpetic, TB
Symptoms• Red eye (usually unilateral)• Pain• Blurred vision• Photophobia• NO discharge• NOT sticky
Examination
Circumcorneal
conjunctival injection
Keratic precipitates (inflammatory cells) on
corneal endotheliu
m
Examination
Flare (albumin leakage from iris vessels)
Inflammatory cells in the
anterior chamber -
hypopyon if severe
Miosis
Posterior synechiae (adhesions
between iris and lens)
Acute anterior uveitis (iritis)
Complications
May be associated with raised intraocular
pressure (IOP)
May become chronic and
develop secondary cataract +/-
macular oedema leading to reduced
vision
The condition is likely to recur and
in either eye
Treatment
Dilate pupil to prevent ciliary
spasm and break posterior synechiae
Intensive topical steroids, initially 1-
2 hourly then gradually reduce over next 4-6/52
In severe cases a subconjunctival
injection of steroid +/- mydricaine
(dilating agent) is necessary
Causes
High hyperopia
Advancing cataract
NOT related to
POAG
Symptoms
Nausea / vomiting
Painful red eye
Hazy vision
Haloes around bright lights
Examination
Hyperaemia +++
Fixed mid-dilated pupil
Hazy cornea
Epiphora
Complications
Rapid and complete visual loss
Aetiology is usually bilateral
Acute angle closure glaucoma
Acute angle closure glaucoma
Acute angle closure glaucoma
Palpate the eye to approximate IOP
Question 5:
What to do about floaters / flashing lights
Don’t panic – most cases will be a PVD
Could it be migraine??
If there is a retinal detachment – at BMEC: ‘Macula on’ – 24-48 hours ‘Macula off’ – 5-7 days
‘Macula On’ versus ‘Macula Off’
‘Macula On’ versus ‘Macula Off’
Other important conditions…..
Temporal arteritis
Causes
Spread of local infection• Sinusitis• Eyelis
Symptoms
Fever
Painful red eye
Eyelid swelling
Reduced vision
Diplopia
Examination
Engorged conjunctival
vessels
Conjunctival chemosis
Restricted EOM
Proptosis
RAPD
Complications
Optic nerve compression
Exposure keratitis
Rapid and complete visual
loss
Intra-cranial spread
Orbital cellulitis
Orbital cellulitis
Under active ophthalmic review
Sudden, painless visual loss
Please do not refer (if spontaneous)
Quiz
At 5 pm on a Thursday afternoon…….
68 year-old woman Previous right eye retinal
detachment 2 days history of left flashing lights /
floaters Right VA 6/36, Left VA 6/9 Pupil reactions normal
At 11 am on a Friday morning…….
76 year-old woman Hypermetrope ‘Optician says I have cataracts in both
eyes’ 2 months intermittent left eye pain,
redness and hazy vision Right VA 6/12, Left VA 6/24 Pupil reactions normal
Quiz
At 9 am on a Monday morning…….
26 year-old man Awoke this morning with a painful, red left
eye ‘Short-sighted’ Slept in contact lenses overnight from
Saturday Right VA 6/12, Left VA 6/18 (wearing old
specs) Pupil reactions normal
Quiz
At 2 pm on a Monday afternoon…….
26 year-old man 1 week history of red, gritty eyes and
discharge Partner had sore throat and ‘flu
symptoms Baby daughter recently had red eyes Right VA 6/9, Left VA 6/9 Pupil reactions normal
Quiz
At 6 pm on a Tuesday afternoon…….
36 year-old man Recent nose bleeds and short of breath Difficulty with left hearing Past 3 days unable to sleep with painful,
red right eye and some photophobia No response with paracetamol /ibuprofen Right VA 6/12, Left VA 6/9 Pupil reactions normal
Quiz
At 10 am on a Tuesday morning…….
76 year-old woman Feeling generally unwell, off food, losing
weight, difficulty sleeping Night sweats 2 weeks Headache Right VA 6/9, Left VA 6/9 Pupil reactions normal
Quiz
Key Points
Purulent discharge = bacterial infection Photophobia = keratitis, uveitis Reduced vision = keratitis, uveitis, angle
closure glaucoma Pain = scleritis, angle closure glaucoma,
keratitis, uveitis Hazy cornea = angle closure glaucoma,
keratitis, uveitis Contact lens wearer and sticky eye =
must exclude bacterial keratitis
In summary: easy ‘rules of thumb’
VA and pupil examination are crucial
Refer any CL wearer with red eye or pain
Become familiar with a limited range of lubricant drops and stick to them
If giving drops >4x/day then they should be PF (preservative free)
In summary: easy ‘rules of thumb’
Please don’t prescribe ocular topical steroids in primary care – great potential for ‘disaster’ Please do provide topical steroids if ongoing eye review
Squinting children Recent onset: refer urgently to eye cas Long-standing: refer to clinic
Temporal arteritis No visual symptoms – refer to rheumatology Visual symptoms – refer to ophthalmology