Transcript Idiot`s guide to eye problems

Idiot’s guide to eye problems
Cass Adamson
January 2011
What do GPs need to know?
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Many conditions
Wealth of info
GP books short chapters
Serious consequences if wrong
Take home message:
• If in doubt – REFER!!!
Session plan:
• Presentation on assessing and managing
common or serious eye problems
• Videos on eye examinations (optional)
• Practical session for practising fundoscopy
and other eye examinations
• CSA practise
Eye assessment
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External examination of eyes and face
Visual acuity
Visual fields
Pupils + swinging torch test
Fundoscopy
Eye movements
“There’s something in my eye”
• Joan Peters 65
• Controlled hypertension
• 5/7 ago sudden appearance of ‘tadpole’ in
L eye with some flashing lights.
• No trauma
• Vision NAD
• BP 148/79
• Eyes appear
normal
• PEARL
• Eye movements
NAD
• Fields NAD
• VA (with glasses)
R – 6/5
L – 6/6
Fundoscopy:
What do you do?
a)Reassure her
b)Advise optician r/v
c)Ask about foreign travel and explain that
the ‘tadpole’ could be a worm
d)Refer routinely
e)Refer urgently
f) Refer immediately
• Posterior vitreous detachment
- normal examination
- Floater black ‘cobweb’ or ‘curtain’
• But new flashes and floaters are retinal
detachment or retinal tears until proven
otherwise.
→ refer urgently
Retinal detachment
• Rhegmatogenous or
traction.
• Flashes, floaters and
field loss – curtain from
periphery
• Blurred central vision
Retinal tear
Vitreous haemorrhage
• Flashes and floaters
• Floaters large and red
or black
• Tearing or bleeding
• Floating blobs or
severe visual loss
“It’s double vision, Doc”
• Hanif Khan 47
• Occasional headaches
• Last night sudden onset diplopia and a
headache which is worsening.
• Taken some ibuprofen, partial relief
• L eye looking
down and
outwards
• Unable to look up,
down or medially
• Partial ptosis
• L pupil slightly
dilated and less
reactive to light
What do you do?
a) Inform him it is a CN III palsy and to
come back if his symptoms worsen
b) Prescribe analgesia for headache
c) Ask optician to examine fundi then r/v
patient
d) Refer routinely
e) Refer urgently
f) Refer immediately
• New sudden onset diplopia adult has a life
threatening cause eg aneurysm until
proven otherwise → immediate referral
• Gradual onset diplopia in adult can be
tumour.
• Can see transient or persisting diplopia
with temporal arteritis
Causes of diplopia:
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Intoxication
Head injury
CVA
Orbital floor #
Guillain-Barre
Myasthenia gravis
Early cataract
CN III, IV, VI palsies
• Other signs to look
for:
• Enlarged pupil, ↓ response
light – CN III palsy
• Ptosis – CN III palsy or MG
• Lid retraction – thyroid eye
disease
• Red eye – thyroid eye disease
or orbital inflammation
• Ocular torticollis – CN IV palsy
Blurred vision:
• Serious eye/brain
disease likely if
symptoms:
- Unexplained eye pain
- Photophobia
- Distortion vision
- Flashes of light
- New floaters
- Loss part visual field
- Sx temporal arteritis
• Serious eye/brain
disease likely if
signs:
- Red eye
- Visual field defect
- RAPD
- Abnormal cornea, iris
or pupil
- Loss red reflex
- Optic disc swelling or
pallor
“ I can’t see in my left eye!”
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Hannah Cook 76
Type 2 diabetes and hypertension
This morning sudden reduced vision L eye
Mildly painful
DH: bendroflumethiazide, metformin,
simvastatin and aspirin
• BP 156/66
• Last HbA1c 7.9%
• VA (with glasses)
R – 6/9
L – 6/18
• Eye movements NAD
• Possible RAPD
• Fundoscopy:
What is it?
What do you do?
a) Review her medications and add in a
further agent for BP and DM
b) Make sure she sees her optician soon as
her glasses are clearly inadequate
c) Refer routinely
d) Refer urgently
e) Refer immediately
Central retinal vein occlusion:
• Widespread retinal haemorrhage
• Tortuous dilated veins
• Macular oedema
• Optic disc swelling
• +/- cotton wool spots.
Proliferative Diabetic Retinopathy:
• Cotton wool spots
• Hard exudates
• Dot and flame haemorrhages
• Branch retinal vein
occlusion:
• Appearance similar to
CRVO
• Sx: sudden blurring or
field defect
• Central retinal artery
occlusion:
• Sudden painless loss
all vision
• ↓↓↓ VA (light only),
RAPD
• Pale retina, cherry red
macula
Transient visual loss:
One eye or both?
ONE
Amaurosis fugax
-Carotid stenosis
- Temporal arteritis
Transient obscurations
-Papilloedema
-Orbital tumour
BOTH
Migraine
Vertebrobasilar TIA
Papilloedema
Occipital tumour
Sudden or rapid visual loss:
One or both?
ONE
BOTH
RAPD and/or
Field loss?
YES
Acute retinal detachment
Major retinal vascular occlusion
Acute optic neuropathy
Other acute retinal disease
Bilateral acute optic neuropathy
NO
Minor retinal vascular occlusion
‘wet’ ARMD
Vitreous haemorrhage
Other macular or retinal disease
Gradual visual loss:
RAPD and/or field loss
present?
YES
Slowly progressive optic neuropathy
Advanced chronic glaucoma
Chronic retinal detachment
NO
Cataracts
‘dry’ ARMD
Diabetic maculopathy
Other macular disease
“My eyes keep going funny”
• Jemima Duck 26
• Had headache past 3/52. 4/7 when
bending forwards nausea and transient
visual loss
• BMI 29.6
• Takes COCP
• No PMH
• ?RAPD (subtle)
• Eye movements NAD
• VA
L - 6/9
R – 6/12
• Fields - ?central
scotoma
• Fundoscopy
(bilateral):
What do you do?
a)
b)
c)
d)
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Refer for routine CT/MRI head
Refer for urgent CT/MRI head
Call 999
Admit medical team
Refer to ophthalmology routinely
Refer to ophthalmology urgently
Papilloedema:
• Unilateral – disease within eye
• Bilateral - ↑ICP
“My eye is droopy”
• Bob Smith 54 year old smoker.
• 5/7 drooping L eyelid, worsening
• Otherwise asymptomatic
• Possibly some weight
loss
• Longstanding mild dry
cough
Probable Pancoast’s
Syndrome
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Other causes:
Head or neck trauma
Brainstem stroke
Dissecting internal
carotid aneurysm
Approach to ptosis:
• Bilateral: age related or MG
• Mild: Horner’s syndrome
• Double vision or limited eye movements:
MG or CN III palsy
• Pupil small: Horner’s
• Pupil large: CN III palsy
• Fatigability: MG
→refer
“My eye looks odd”
• Sarah Brown 19yr.
• Her mother noticed her R eye looked ‘odd’
this morning.
• Recent bad cold.
• No PMH
• Takes COCP
• Adie’s pupil
• Unilateral dilated pupil
• Poor or no response light.
Unequal pupils:
Do pupils constrict
normally to light?
YES
NO
Smaller pupil
abnormal
Larger pupil
abnormal
Mild ptosis
same side?
Ptosis same side,
Double vision or
Abnormal eye
movements?
YES
NO
Possible Horner’s syndrome
YES
NO
Possible anisocoria
Likely partial CN III palsy
Adie’s pupil
Previous iris trauma or disease
Dilating substance
More words of wisdom:
• Not all flashing lights with headache are
migraine
• Blurred vision or headache needs field test
• Field loss always needs assessment
• Sudden onset visual distortion – urgent ref
• Consider temporal arteritis every pt >50
with headache or visual change
• Red eye with decreased vision, pain or
photophobia needs same day referral.
• Any child with a turned eye has sight/life
threatening condition unless disproved
• New onset flashes and floaters are retinal
detachment until proven otherwise
References:
1. Pulse Plus – Ophthalmology
2. Pulse – Picture quiz: Acute Referrals to
Ophthalmology
3. Practical Ophthalmology – A Survival Guide for
Doctors and Optometrists (2005). A. Pane and
P. Simcock
4. Symptom Sorter 4th ed (2010). K. Hopcroft and
V. Forte
5. The 10-Minute Clinical Assessment (2010). K.
Schroeder
6. Google images!
Funsdoscopy:
• http://www.heine.com/eng/INFOCENTER/INFORMATIONLITERATURE/Filme-undNeuheiten/Direct-Ophthalmoscopie