Transcript GP Ophthalmology - My Surgery Website

GP Ophthalmology
• 60 in 1000 consultations are for eye problems
• 1 or 2 consultations a day
• 10-15% of all “eye” consultations are for conjunctivitis
Commonest Problems referred
to Eye Casualty
1/. Persistent red eye or unresolving conjunctivitis
2/. Corneal FBs/ Corneal abrasions
3/. Flashes and Floaters
4/. Painful eye (Iritis/keratitis)
5/. Reduced vision
6/. Lid problems (styes, chalazions etc)
7/. Contact lens problems
8/. Cellulitis/periorbital swelling
9/. Ophthalmic shingles
Commonest “Mismanagements”
1/. Iritis treated as conjunctivitis
2/. Late referral of Keratitis/Corneal Ulcers
3/. Missed herpetic Ulcers
4/. Missed foreign bodies
5/. “Loss of Vision” (Vision not checked and
longstanding)
6/. “Acute Glaucoma” that is not. * GP view might
be different!
7/. Episcleritis *Harmless condition *GP view
might be different!
Essential Equipment
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Visual Acuity Testing Charts.
Snellen for adults. (“E” chart with card or Sheridan Gardner for illiterate)
Sheridan Gardner for Children >3 yrs
Kay picture cards for Children > 2yrs
Babies >3/12 following
>8/12 100s and 1000s or Preferential looking cards (Orthoptists best)
Pinhole
Ophthalmoscope Blue filter, Green filter for new vessels
Illuminated Magnifying Glass (Auroscope without speculum is good)
Epilating forceps for ingrowing
Fluorets
Proxymetacaine Minims (sting less than Amethocaine)
Tropicamide 1% Minims
Amsler Charts
Ishihara Charts (Red/Green Colour blindness, Optic Neuropathy)
(Red and White Pins (White peripheral VF, Red central VF))
Case Study 1
27 year old builder presents complaining of a FB in his RE
His eye is sore and watering and the vision is blurred.
He has washed the eye out and it is no better
He is seen and a central corneal FB is noted. It is nonmetallic and is easily removed with a green needle
The cornea appears clear and he is prescribed
Chloramphenicol and advised to attend 3 days later to
make sure the cornea has healed.
Is there anything anyone would do differently?
He returns 10 days later (he was very busy and
could not get away earlier)
• He says his eye is now very painful and his vision
is very blurred
• On examination his vision is HM only
• He has a complete hypopyon and a small
conjunctival puncture wound is noted
• He was chiselling when the FB hit his cornea
• An USS shows an IOFB.
• He is referred to Oxford where he has a total
vitrectomy and removal of his FB
• 2/12 later his vision has improved to 6/24
Failings
• Inadequate history
• Vision not checked at presentation
• Inadequate examination, conjunctiva not
checked, Fundus not checked
History
Presenting Complaint
• Onset/Triggers (trauma etc)
• Vision
• Pain/Photophobia
• Discharge
• Other symptoms (itching/floaters/flashes/diplopia etc.)
• Treatment
Past Ophthalmic History
• Iritis
• *Eye Surgery/treatment
• Glasses or Contact lenses
• *Previous Vision
Past Medical History
• Diabetes
• Connective tissue disease (RA etc)
• Vascular disease
• Atopy/Asthma etc
Smoking
FH
• Glaucoma, Retinitis pigmentosa etc
Drugs
• Steroids
• Chloroquine
• Amiodarone.
Examination
Have a system:
Outside to inside of lids.
Front to Back of eye.
(Requires discipline to stick to)
Vision should always be checked if painful eye or if patient complains of
blurred vision (medico-legal protection)
If VA reduced always recheck with glasses and pinhole
General Inspection Proptosis, exophthalmos, Rosacea, etc
Lids (Beware small BCCs)
Always evert upper lid if FB (use a swab to roll the upper lid)
Conjunctiva Tarsal and Bulbar
Cornea Always stain if pain/photophobia or
herpes on lids
Anterior Chamber Hyphaema if trauma
Hypopyon if pain/ulcer
Pupil Reactions
Shape (irregular if Iritis)
Iris lesions (vessels if CRVO (Rubeosis))
Lens Cataract
Dislocated
Vitreous Occasional small floater seen on
Fundoscopy
Fundus
Have a system.
• Easier if dilated and in dark room
• 15->20degrees temporally, patient looking straight ahead
• Follow vessels to disc
• Disc Margin, Colour, Pitting, Vessels, Venous Pulse (?)
• Macula any abnormality should be taken seriously
• Follow out vascular arcades
• View periphery. Patient to look into 4 or 8 directions
(up/right/down/left/)
Eye movements if relevant (eg double vision)
Visual fields to confrontation if relevant (red and white pins if keen)
Defects:
Bitemporal: Chiasmal
Homonymous:Behind chiasm
All others: In front of chiasm (Nerve or eye)
Case Study 2
Red Eye
A 23 year old woman presents with red eyes
that are watering and burning.
What else would you want to know before
making a diagnosis
Some considerations
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Contact Lens wearer?
Trauma?
Other family members affected Infective
Onset ? Monocular/ binocular (allergy binocular)
Pain/Photophobia? Suggests Keratitis (beware
Herpetic Ulcer)
Vision?
If burred Suggests keratitis (bilateral iritis
unlikely)
Discharge?
Purulent:Bacterial
Watery: Viral/allergic
Itching? More likely to be allergic
Treatment ? Allergy to drops
Systemic illness? URTI often accompanies viral
conjunctivitis
Conjunctivitis
Blepharitis
Episcleritis
Pinguecula
Pterygium
Subconjunctival
Haemorrhage
Herpes Simplex Conjunctivitis
(always stain)
Case Study 3
Painful Red Eye
A 56 year old man presents with a painful
red eye.
What else would you want to know?
Painful Red Eye
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Onset. Acute? Any trigger?
Past Ophthalmic history: Iritis? Recent surgery?
Past Medical history RA etc
Vision? Blurred in Iritis and keratitis. Very blurred in
Acute Glaucoma
Trauma? Detailed history important. ?FB sensation
?Likley to have a hyphaema
(E.g. squash ball injury). ?contact lens wear?
Pain. Very severe in Acute Glaucoma often with vomiting
Photophobia? Marked in keratitis and Iritis
Discharge? Muco-purulent suggests possible infective
cause, although most painful eyes water a lot
Acute Glaucoma
A Medical Emergency needs urgent referral.
Optic nerve can be killed within a few hours due to ischaemia if
not treated. Principles of treatment are constricting the pupil to
unblock the angle and reducing pressure with agents such as
diamox
Acute Iritis
Keratitis
• A breakdown of corneal epithelium. Caused by trauma, infection, contact
lens over wear, dry eyes and exposure
• Cornea looks rough, but best seen with Fluorescein staining
• Beware Herpes Simplex. Starts as a branching epithelial ulcer that can
spread deeper to cause a large geographic ulcer with subsequent scarring and
even perforation.
Dendritic Ulcer
If Pain Refer
If blurred vision and
photophobia Refer
Case 4
Eye lid lump
A 68 year old presents with a lump on his
eye lid
What are the likely diagnoses?
Basal Cell Carcinoma of the upper lid
Beware BCC. Easily missed, often picked up
as an incidental finding. If large and eroding
through tarsal plate can lead to loss of
eyeball as impossible to achieve coverage of
eyeball after removal
Chalazion
Stye
Herpes Zoster Ophthalmicus
Nasocilliary branch
involved with
vesicles on side of
nose meaning that
ocular involvement
much more likely.
(Hutchinson’s Sign)
Case 5
Flashes and Floaters
A 60 year diabetic gentleman with severe
myopia presents with a history of floaters
in his Right eye
What else would you like to know?
What are the likely possible diagnoses?
Useful History Points
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Duration
Past Ophthalmic history
Any recent change
Any flashes (Suggest RD or PVD)
Visual loss or blurring (Suggests Vit haem
or detachment)
Curtain effect suggests Retinal
detachment.
Diagnoses
• Vitreous haemorrhage (Commoner in
diabetics)
• Posterior Vitreous detachment (Common,
can sometimes cause vit haem, 10%
cause retinal tears).
• Retinal detachment.Commoner in
Myopes( short sighted with thick glasses
that make things small)
Case 6
Sudden Loss of Vision
• A 75 year old gentleman presents
complaining of a sudden loss of vision in
his left eye
What else would you like to know?
What are the likely diagnoses?
Useful History Points
• Pain suggests Acute glaucoma
• Flashes and floaters before suggest Ret
Detachment or possible Vitreous haem
• Ph of Diabetes suggests haemorrhage likely
• Ph of Eye surgery suggests Retinal detachment
or macula oedema likely
• Ph vascular disease suggests an embolism
• Ph hypertension suggests a CRVO as a
possibility
• Headaches/muscle aches and thick temporal
arteries suggest temporal arteritis
Central Retinal Vein Occlusion
Normal Fundus
Retinal
Detachment
(Macula off)
Central Retinal Artery Occlusion
Vitreous Haemorrhage
Temporal Arteritis
Acute Angle Closure Glaucoma
Case 7
Blurred vision
An 84 year old presents complaining that
“her eyes are not so good”.
What else would you like to know?
What are the likely diagnoses
Useful History Points
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Monocular or Binocular
Past ophthalmic history
Previous vision
Recent opticians visit?
Past medical history
Nature of disturbance
Glare in bright lights (Cataracts)
Central distortion (Macula degeneration)
Dry Macular Degeneration
Case 8
A 66 year old lady presents complaining of
persistently watery eyes for a long time. The
eyes are not red or itchy but occasionally gritty.
The antibiotic prescribed by your partner a
month ago have not helped. Her vision is
normal.
What else do you need to know?
What are the likely diagnoses?
Other History Points
• When they water. Has she had any recent
injury or other treatment?
• Any new allergens?
Likely diagnoses
• Blocked tearduct (previous nasal fracture)
• Senile ectropion
• Dry eyes with reflex hypersecretion
If treating dry eyes long term remember lid
cleaning and preservative free drops (e.g.
Celluvisc and Refresh)
Senile Ectropion
Macula Degeneration
• Commonest cause of blindness in the over 50’s in the Western
World
• 1% 55-65 year olds have visually significant disease
• 6% 65-75 year olds
• 20% >75 year olds
Risk factors
• Smoking
• Female>Males
• White > Black
• Diet
• Hypermetropia
• Cardiovascular disease
2 main types
Dry
• Gradual onset
• Symptoms of central distortion
• Requires monitoring c Amsler grid
Wet
Much less common
Can cause sudden distortion of vision
Caused by new leaky blood vessels growing
through from Choroid
Treatment
• Address risk factors
• Diet/Vitamin supplements
• Anti VEGF agents such as Lucentis, Macugen
and Avista for “WET” only
• Clear evidence that they slow progression in
90%
• Clear evidence of improvement in Vision in 30%
• Very expensive - £28,000 for a course of
Lucentis injections
• Only £5,600 for Avista but unlicensed.
Cataracts
• 40% of all blindness worldwide caused by
Cataract
• 16% of 65-69 year olds have visually
significant cataracts
• 42% of 75-79 year olds
• 71% of 85 year olds
Risk Factors
• Age
• Smoking
• Sunlight
• Alcohol
• Dehydration
• Radiation
• Steroids
• Diabetes
Symptoms
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Blurred vision
Glare in bright lights
Monocular diplopia
Become more myopic
Treatment
Extraction usually by phacoemusification
Complications of Surgery
• Macula oedema, detachment,
haemorrhage, inflammation etc
• Late: Posterior capsular thickening treated
by Laser
Phacoemulsification
Glaucoma
• 20,000 new cases per annum
• 20,000 with ocular hypertension
2 main types
Angle closure
• Leading to Acute Glaucoma
• Rare but serious and sight threatening. An ocular emergency
Open angle
• Commonest
• Diagnosed on the basis of three abnormalities
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Pressure >21mm Hg
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Disc changes
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VF changes (nasal step, arcuate scotoma etc)
Angle Closure Glaucoma
Risk Factors
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Age
Family history
Afrocarribean > Caucasian
Myopia
Steroids
Hypertension and diabetes
Treatment
Angle closure:
• Peripheral iridectomy after emergency pressure
lowering (also to other eye)
Open angle
• Usually medical with eyedrops
• Prostaglandin analogues (increase aqueous
outflow)
• Beta blockers (decrease aqueous production)
• Carbonic anhydrase inhibitors (decrease
production)
• Sympathomimetics.
Glaucomatous Disc
Diabetic Retinopathy
• Background Dot and blot haems hard
exudates
• Preproliferative Cotton wool spots Refer
• Proliferative New Vessels, cotton wool
spots Refer
• Maculopathy Refer
• If vision down Refer
Multiple Cotton Wool Spots
Key Learning Points
• Take a good history especially if trauma
• Always check Vision if patient complains of
blurred vision or pain
• Always check vision with a pinhole if VA
reduced on first check
• Beware BCC on eyelids
• Always stain painful/photophobic/blurred or
herpetic eyes, or if trauma
• Always refer painful/blurred/photophobic red
eyes
• Never use steroid drops without staining (if
ever).