Transcript Davinas_Eye_Presentation_2.pps

Eye Essentials For General Practice
Davina Sehgal
Presentation Content
• Brief introduction
• Common ocular symptoms
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Red Eye
Painful / Itchy Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
• Primary Open Angle Glaucoma
• Ophthalmoscopy Technique
• Q&A
Introduction
• Practicing for over 8 years
• Work as locum based in the Observatory in
Muswell Hill
• Eye problems account for 2% of all GP
consultations
Common Ocular Symptoms
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Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
Red Eye
Red Eye
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Subconjunctival Haemorrhage
Bacterial Conjunctivitis
Viral & Allergic Conjunctivitis
Iritis – Uveitis
Scleritis & Episcleritis
Foreign Body
Closed Angle Glaucoma
Subconjunctival Haemorrhage
Subconjunctival Haemorrhage
• The only type of red eye which has no
symptoms
• Conjunctiva has bright & solidly red
appearance
• Most common reason is idiopathic, no need to
refer
• Carry out full blood check if it happens
recurrently due to risk of high BP
Bacterial Conjunctivitis
• One of the most commonly encountered eye
problems in medicine
• A sticky, yellow, mucousy eye discharge
• Can be severe enough to cause the eyelids to
be stuck together on awakening
• Conjunctiva has a pinker appearance
compared to subconjunctival haemorrhage
• Chloramphenicol
Viral Conjunctivitis
• Can be difficult to differentiate from bacterial
• No discharge, just watering
• The signs on ophthalmic exam which suggest
viral over bacterial:
• Follicles on tarsal conjunctiva (look like translucent
rice grains!)
• Concurrent pharyngitis, fever, and upper respiratory
infection
• Patients will often have symptoms of a common
cold
• No eye drops or ointments are effective against
the common viruses that cause viral
conjunctivitis
Viral Conjunctivitis
Iritis – Uveitis
• Uvea = iris, ciliary body & choroid
• Important deferential diagnosis from
conjunctivitis
• Presents with fairly sudden onset painful (dull
ache), red eye with photophobia and reduced
vision
• Symptoms can therefore be similar to
conjunctivitis but headache just above affected
eye common. May also see a small or distorted
pupil relative to the other eye.
• Sometimes an increase in floaters due to
aqueous cells & flare
Iritis – Uveitis
• Usually unilateral
• If left untreated, posterior synechiae can form
(adhesions between the anterior surface of the
capsule of the lens and the iris) causing iris
bombe which can raise IOPs
• If these are extensive they may impede the
normal flow of aqueous leading to the
peripheral iris being pushed forwards and
causing iris bombe, raising IOPs.
• Tends to affect middle aged or younger people,
especially men (not common in children)
Iritis – Uveitis
• Can be associated with certain autoimmune
disorders such as rheumatoid
arthritis or ankylosing spondylitis
• EMERGENCY!
Episcleritis
• Inflammation of the episclera (lies between the
conjunctiva and the sclera)
• Usually benign & idiopathic
• Localised area of redness
• No or very mild discomfort/grittiness
• Lasts approx 7-10 days before spontaneously
resolving
• Treatment is not usually
required but artificial tears
may
provide some relief
Scleritis
• More severe inflammation that occurs
throughout the entire thickness of the sclera
• Boring pain developing gradually & eventually
becoming severe. Usually bilateral
• Eye may be tender to touch, no discharge
• May be associated with connective tissue
disorders and autoimmune disorders like
rheumatoid arthritis, ankylosing spondylitis &
Crohn’s disease
• One in six people with scleritis have
rheumatoid arthritis - however, only about 1%
of people with rheumatoid arthritis will develop
scleritis, usually if the arthritis is severe.
Scleritis
• Topical non-steroidal anti-inflammatory drugs in
symptomatic patients
• Same day referral to eye hospital
Foreign Body
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FB sensation
Redness, pain, watering
Photophobia
Use fluorescein if you can & blue filter on
ophthalmoscope
• Patients are fairly reliable at locating the FB
• Flush with fluorescein then refer as
emergency
Closed Angle Glaucoma
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Sudden severe eye pain
Blurred vision due to hazy cornea
Bright halos appearing around objects.
Eye redness & tenderness (ciliary flush, ie the
redness is more marked around the periphery
of the cornea)
• Feeling nauseated and
vomiting
• Non-reactive (or
minimally
reactive) mid-dilated pupil.
Closed Angle Glaucoma
• IOP’s severely raised
• More likely to occur in hyperopic patients &
when pupil is dilated
• Refer to eye hospital as emergency!
• Can administer Pilocarpine (miotic) in mean
time
Common Ocular Symptoms
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Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
Itchy &
Watery Eye
Itchy & Watery Eye
• Allergic conjunctivitis
• Affects both eyes
• Presence of papillae
• Most common cause of watery eyes…. Dry
eyes!
• Don’t forget to check lids & lashes:
• Blepharitis
• Meibomian Gland Blockage
• Entropian
Common Ocular Symptoms
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Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
Reduced
Vision
(Sudden or
Gradual)
Reduced Vision (Sudden)
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Sudden onset loss of vision is usually vascular!
Central retinal artery occlusion
Central retinal vein occlusion
Vitreous haemorrhage
Ischemic optic neuropathy (Blockage of an
artery to the optic nerve)
• Giant Cell Arteritis
• Carry out a full blood check
Reduced Vision (Gradual)
• Cataract!!
• Red reflex of ophthalmoscopy less bright
• Nuclear, cortical, posterior subcapsular –
different appearances
• Age! Trauma, diabetes, medications such as
steroids
Common Ocular Symptoms
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Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
Flashing
Lights /
Floaters
Flashing Lights / Floaters
• Very common!
• 3 main causes
• Ocular migraine
• Posterior vitreous detachment (PVD)
• Retinal detachment (most rare but needs to be ruled
out!!)
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Sudden onset ring-shaped floater typically PVD
Px needs to be dilated ASAP
95% of PVDs have no complications
BUT for 3 months after a PVD there is an
increased risk of a retinal tear forming (in 5% of
cases a retinal tear develops)
Retinal Tear / Detachment
Common Ocular Symptoms
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Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches
Headaches
Headaches
• If ocular related most commonly frontal
• Most commonly associated with change in
Rx or ocular muscle imbalances
• Headaches associated with eye pain:
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Acute Glaucoma
Uveitis
Viral conjunctivitis
Papilloema
• Always check optic disc!!
Primary Open Angle Glaucoma
• Damage to the optic nerve normally caused by
raised IOP's, causing irreversible visual field
loss
• No symptoms!
• FH must have annual ST, NHS ST for 40 years
& over
• Advise regular ST!
Case Study
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Age/Sex/Race
33 year old male
Chief Complaint
“My right eye has been red for past three days. It started in the
evening three days ago. It was watery and I have dull, throbbing
pain.”
• The patient is light sensitive. No signs of itching, burning or flashing
lights. Gets the occasional floaters but always has done.
• Ocular History
• The patient said that she knows that she needs glasses for distance
but hasn't seen an Optometrist for a few years.
• Medications - None
• Family History
• Mother – Gout, Rheumatoid Arthritis
Case Study
• What further questions will you ask the patient &
what tests will you carry out?
• Extraocular muscles: Full
• Pupils: PERRLA, No RAPD but RE pupil slightly
distorted
• Slit lamp examination:
• Lids/lashes – clear
• Conjunctiva – General bulbar redness with
circumlimbal injection LE, clear LE
• Cornea – mild edema OD, clear OS (slightly hazier red reflex
compared with LE).
Case Study
• On questioning: Px has not noticed a deterioration in
vision but on VA testing, is surprised to see that the RE
has reduced to 6/12.
Dull ache over RE since yesterday.
• ANTERIOR UVEITIS
• SAME DAY REFERRAL TO MOORFIELDS OR
NEAREST EYE HOSPITAL!!
Case Study 2
• Px attends c/o headaches..., you check optic discs
& find this:
• What does it mean?
Q&A
Ophthalmoscopy Technique
• Start on black +10 lens at about 10cm from
patient
• Should always be a bright red reflex (unless
presence of media opacities)
• Click downwards (ie reduced power of lens) &
locate a blood vessel
• If you increase the negative (or red) numbers,
you will focus in objects further away.
• Follow blood vessel as it get thicker, lead you to
optic disc
• Move nasally to find macula
• 8 positions of glaze to see periphery, will
probably have to adjust lens