Transcript eye problems in general practice

EYE PROBLEMS IN GENERAL
PRACTICE
MAZHAR KHAN
General practitioner
Heaton Medical Practice
Why is ophthalmology important in
General Practice ?
Expect 2 - 5 % of all GP consultations to be
eye related
• What do you do when you see a patient with new
onset AF who suddenly wakes up in the morning with
loss of vision in one eye?
• What do you do when you see an elderly woman with
nausea/vomiting? Your working diagnosis is
Gastroenteritis but she has a rt painful red eye. Is it
just conjunctivitis?
• A patient with Rheumatoid Arthritis has been
complaining of sore, gritty eyes for a week. You have
tried ocular antibiotics and its not getting better. Is
there something else going on?
General Practice
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Infective Conjunctivitis 44%
Allergic Conjunctivitis 15%
Meibomian Cyst 8%
Blepharitis 5%
Cataract 4.8%
Abraision/ F body 3%
Glaucoma 2.3%
Stye 2%
Macular disease 1.1%
Ant Uveitis 1.1%
No abnormality 1.8%
Other conditions 11.9%
A&E
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Foreign body 29%
Corneal abrasion 15%
Eye injury/trauma 15%
Infective Conjunctivitis 9%
Allergic Conjunctivitis 3%
Lid inflammation 3%
Other conditions 26%
Things to have in the clinic
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Snellen Chart
Ophthalmoscope
Fluorescein
Pen-torch with cobalt filter
Pin hole
Tropicamide 1% / Cyclopentolate 0.5/1%
Phenylepherine 2.5%
Amsler Grid
Local anaesthetic – Benoxinate/ Amethocaine
Anatomy of the human eye
Good history taking is vital
• History of presenting ophthalmic
complaint/s
• Past ophthalmic history is important
• Current medical problems/ medications
• Past medical history could hold the clue
Basic ophthalmic examination
• Visual acuity for distance (Snellen chart/ Sheridan Gardner test) and reading (near vision testing card)
• Visual fields by confrontation method
• Colour vision by using Ishihara’s chart
• Eye lids, lid margins, eye lashes
• Eye surface – conjunctiva, cornea, iris, sclera/ episclera
• Anterior chamber using a slit-lamp
• Pupils – not just PERLA
Basic ophthalmic examination
• Extra-ocular movements
• Examination of ocular media
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Dark room
Use a mydriatic
Cornea
Lens
Red reflex
Vitreous
Retina (optic disc, cup: disc ratio, arteries, veins,
exudates/hemorrhages, macula)
READY FOR SOME EYE SCENARIOS ?
SCENARIO 1
This 42 yr old patient presents with a 2 day Hx/o gritty, red lt eye
which has become sticky over the last 24 hrs. His rt eye doesn’t feel
right today as well. His vision is normal
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What is the diagnosis and etiology?
What are the clinical features you can see?
What other similar conditions should you differentiate it from?
How would you treat this patient?
How would you manage sticky eyes in babies?
Viral Conjunctivitis
Follicular changes
Hemorrhagic changes
Allergic Conjunctivitis
Perennial conjunctivitis
Vernal conjunctivitis
Atopic conjunctivitis
Giant papillary conjunctivitis
SCENARIO 2
This patient attended his GP with a sore red eye and was treated with
drops containing both a steroid and an antibiotic preparation. Three
days later he returned saying his vision was blurred and his eye was
more painful and intolerant to light
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What can you see on examination & what is the diagnosis?
What is the cause of this condition?
What stain has been used here? Which stain would be more usual
to use?
What are the possible complications?
How would you manage this patient?
Is there any treatment that you would avoid in this condition?
Corneal Ulcer
Non infective
- Contact lens
- Trauma
- Previous corneal problems
infective
bacterial
viral
fungal
protozoal
ALL CORNEAL ULCERS SHOULD BE REFERRED URGENTLY DUE TO
SIGHT THREAT
scenario 3
This 68 yr old patient presented to his GP with eye irritation and
redness often worse when his central heating is on
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What tests are being performed in the above diagram and how are
they done?
What is the condition and its causes?
How do you treat this condition?
Scenario 4
This 19 yr old medical student complains of irritation of the eye lids.
It has become much worse recently while studying for exams
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What is this condition?
What are the usual typical features?
What is the underlying predisposition of these patients?
What are the possible complications of this condition?
Describe the treatment
Any worries about certain treatment?
Scenario 5
This 21 yr old patient presented to his GP with a red painful swelling
over his eye lid
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What is the condition?
What is the etio-pathology?
How would you treat this patient?
What other conditions cause similar eyelid swellings?
Meibomian Cyst
Basal cell carcinoma
Cyst of Moll
Cyst of Zeiss
Scenario 6
This 19 yr old female presented with a 2 day hx of pain, redness,
intolerance to light, excessive watering and blurred vision
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What is your diagnosis?
What are the above examination findings?
What is the cause?
What complications could arise?
How would you treat this condition?
complications of uveitis
Hypopyon
Secondary Cataract
Scanario 7
This 67 yr old patient presented with terrible pain in one eye and
blurred vision for over 12 hrs. He now has a throbbing headache
vomiting and his vision is getting worse
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Describe this picture
What is your diagnosis?
What are the types of this condition?
How will you manage this patient?
Scenario 8
Mrs Walker phones you whilst you are oncall at 6.30pm (just as you
were about to go home). She says her 69 yr old hemiplegic husband
has suddenly lost vision in his rt eye. Mr Walker also has a past Hx
of Atrial Fibrillation
Fig 1
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fig 2
You visit Mr Walker at home and note that his fundus appears as
in fig 1. Describe the 2 pictures and mention your primary
diagnosis?
Based on the history/ symptoms what would be your differential
diagnosis?
How will you manage this patient?
C.R.V.O
Retinal detachment
Vitreous Hemorrhage
Amaurosis Fugax
Scanario 9
A 21 year old patient has come to see you today to get his eyes
checked. He wants to start driving but is not sure if his vision is fine.
On Snellen’s chart he can only read 3 letters in row 5 with the lt
eye and 3 letters in row 4 with the rt eye.
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How will you record his V/A on a paper?
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Which is his better eye?
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How will you advice about the
appropriateness of driving?
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Is there any other way you will test his
vision for driving?
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He tells you he wants to apply for a job
in a removal company. Is he allowed to
drive a HGV?
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What is the law?
Scenario 10
A 65 yr old patient presents to you with a watery lt eye.
Fig 1
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Fig 2
What are the possible causes of excessive lacrimation (epiphora)?
What are the conditions in figures 1 and 2?
What causes can you think of leading to the above conditions?
What are the possible complications for the above?
How would you manage both conditions?
Scenario 11
This 28 yr old patient has a 5 day Hx of red and painful Lt eye. There
is no discharge and his vision is normal
Fig 1
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Fig 2
What is the diagnosis?
What are the 2 types of this common condition shown in fig 1 & 2?
How will you manage this condition?
What is the severe form of this condition and its complications?
Spot the diagnosis
Sub Conjunctival Haemorrhage
Posterior Subcapsular Cataract
Age Related Macular Degeneration
Background Diabetic Retinopathy
Proliferative Diabetic Retinopathy
Pre-proliferative Diabetic Retinopathy
Advanced Diabetic Retinopathy
Compensated (I/ II) Hypertensive
Retinopathy
Accelerated (iii/ iv) Hypertensive
Retinopathy
BUT DON’T MISS
Peri-orbital Cellulitis
Orbital
Cellulitis
THE
MORE
SERIOUS
CONDITION. NEXT
Pterygium
A woman presented to her GP with a Hx of floaters in her lt eye.
Fundoscopy showed a blurred area at the centre of macula
Two more patients presented to the same GP that week needing a
Fundal examination, and both displayed similar findings in their lt
Eyes only.
IS THE OPHTHALMOSCOPE FAULTY?
The GP referred himself to the ophthalmology department and was
diagnosed as having lt central serous chorioretinopathy. It took 4
months to resolve leaving residual retinal pigmentary change
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History is extremely important in making a diagnosis
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Always carry a Snellen’s chart with you
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NEVER FORGET TO STAIN A RED EYE
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Ophthalmic examination is not that difficult – It does get easier
with practice IF YOU MAKE AN EFFORT
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All you need is a working knowledge in ophthalmology and some
basic skills to figure out the problem. You are not expected to
treat complicated eye problems
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Opticians/Optometrists are valuable resources available to
GP’s. Make good use of them. It can prevent unnecessary
referrals.
“DON’T TURN A BLIND EYE”