Surgeon Birmingham amp Midland Eye Centre amp BMI The Priory Mr Kim Son Lett PreTriage System Red Need to be seen within a few hrs further triaging Amber Need to be seen within 72 hrs diverted to UCC slots ID: 908094
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Slide1
Consultant Ophthalmologist & Vitreo-Retinal SurgeonBirmingham & Midland Eye Centre & BMI The Priory
Mr. Kim Son Lett
Slide2Pre-Triage SystemRed Need to be seen within a few hrs, further triaging.Amber Need to be seen within 72 hrs, diverted to UCC slots.Green No need for urgent assessment, referred to GP, optometrist or to OPD (via GP).
Slide3Red – Very UrgentPenetrating eye injuryAcute post-op endophthalmitisSevere chemical injuryOrbital cellulitis
GCA with visual symptoms
Sudden loss of vision <6hrs
Slide4Red - UrgentPainful red eye with visual lossRetinal detachment with good VACorneal ulcer, esp. with CL wearBlunt trauma with hyphaema & ↑ IOP
Corneal graft rejection
Painful
diplopia
Slide5AmberFlashes & floaters, no loss of visionRed eye without pain or visual lossRetinal vein occlusions (OPD 4-6/52)Diabetic retinopathy with vitreous haemorrhageWet AMD (preferably refer to Fast Track Macular Clinic)
Slide6Green – GP / Optometrist MxBacterial & viral conjunctivitisAllergic conjunctivitisBlepharitisDry eyesLid lumps and bumps
Slide7Green – OPD ReferralCataractChronic / gradual visual loss (months)Open angle glaucoma, ocular hypertensionWatery eyesEctropion,
entropion
Lid lumps & bumps
Non-acute
diplopia
Slide8TraumaBurnsAcid, alkali, thermal, arc eyeAbrasions & lacerationsLid, corneal and conjunctival, Penetrating Eye Injuries
Foreign bodies
Corneal,
conjunctival
, sub-tarsal, intra-ocular
Blunt trauma
Sub-
conjunctival
haemorrhage,
hyphaema
,
choroidal
rupture
Orbital Blowout Fracture, Traumatic Optic Neuropathy
Slide9Chemical InjuryEmergencyAlkali or AcidpH checkImmediate irrigation
May result in
limbal
stem cell failure
Slide10Corneal AbrasionHistory provides diagnosis & indication of severityMostly doesn’t require A & EOc.
Chloramphenicol
qid
5/7
Slide11Foreign BodiesCan be removed if confidentg. Chlor qid 5/7
Refer
(PEARS?) if
unable to remove or rust rings
Always check for
subtarsal
FB as well
Slide12Sub-conjunctival HaemorrhageSpontaneous vs traumaticSelf limiting
No treatment
No referral required
Slide13Blow Out FractureAssess for globe damage, Traumatic Optic NeuropathyOrbital surgery only if tissue entrapmentNormally performed
within 4/52
Slide14CorneaDry eyeRecurrent erosion syndromeUlcersCL relatedAcanthamoeba
Dendritic
Shingles
Slide15Dry EyesLubricantsLook for blepharitis
Refer OPD only if unable to improve symptoms
Slide16Recurrent Corneal ErosionH/O Index injuryTypically pain on waking / opening eyesOc. Simple / Lacrilube
nocte
3/12
Refer OPD if no improvement
Slide17Bacterial KeratitisEsp in CL wearersExcess wear, poor hygiene
Urgent referral
Differentiate from marginal
keratitis
Slide18Dendritic UlcerTypically HSV 1, as with cold soresSelf limitingTreat with topical Acyclovir / Valgancyclovir
5x/d, 7/7
UCC referral
Slide19Herpes Zoster OphthalmicusOral antiviral Rx if started within 72hrs onset of rashNot always eye involvementHutchinson’s sign
70% chance eye involvement
Most eye involvement doesn’t require specialist Rx
Slide20ConjunctivaConjunctivitisBacterial, viral, allergicEpiscleritisScleritis
Slide21Bacterial ConjunctivitisPurulent / mucopurulent dischargeSelf limiting
OTC g.
Chlor
qid
1/52
No referral required
Slide22Viral ConjunctivitisWatery dischargeFollicular reactionSelf limitingNo referral required unless corneal involvement
Slide23Allergic ConjunctivitisIdentification and avoidance of trigger allergenTopical Sodium cromoglycateOral anti-histamines
No referral required unless persistent problem
Slide24EpiscleritisSelf limitingMild – Moderate discomfortOral NSAIDs, eg ibuprofen
No referral required unless persistence
Steroid dependency
Slide25ScleritisSevere dull boring painBrawny red appearanceStrong association with auto-immune and connective tissue disease
Urgent referral
Needs extensive management
Slide26LidsBlepharitisAnterior, posteriorChalazion, styeEctropion
,
entropion
Pre-
septal
cellulitis
Slide27Anterior & Posterior BlepharitisLid hygieneHot compressesTreat associated dry eye
No referral required
Slide28ChalazionHot compressesI&C if refractoryPrescribe oral Abx if infected
No referral to A & E
Slide29Senile Ectropion & EntropionEnsure lubrication of ocular surfaceNo acute management in A & E
Refer routinely
Slide30Pre-Septal CellulitisNeed to differentiate with orbital cellulitisPt not systemically unwell
No orbital signs
Needs oral
Abx
(GP)
Refer
if in doubt
Slide31Orbital CellulitisPotentially sight / life threatening conditionPt systemically unwell, pyrexial
Orbital signs
Emergency referral
Need admission and IV
ABx
Slide32Neuro-ophthalmologyIIIrd, IVth,
VI
th
nerve palsies
Optic neuritis
Papilloedema
Giant cell
arteritis
Slide333rd, 4th, 6th PalsyMajority will be
microvascular
in elderly diabetic hypertensive population
Consider duration
Beware of painful nerve palsy
esp
3
rd
PCA aneurysm
Beware of assoc headache
esp
6
th
GCA
Slide34Disc SwellingPhysiologicalHypermetropesOptic cupSVPVessel changes
Exudates
Haemorrhages
Hyperaemia
Retinal folds
VISUAL SYMPTOMS?
Slide35Optic NeuritisMostly due to demyelinationUnilateral vs bilateralChild
vs
adult
2/52
↓,
2/52
↔,
2/52
↑
Reduced vision, colour vision, RAPD
Uhtoff’s
phenomenon
Pain
esp
ocular movement
Haemorrhages
Hyperaemia
Venous distension
Swelling
Or no physical signs
Slide36PapilloedemaDue to raised ICPBilateralReduced visionObscurationsBlind spot enlargement
Haems
Hyperaemia
Tortuous congested vessels
Exudates
Cup obliteration
Retinal folds
Slide37Giant Cell ArteritisTemporal headache and tendernessBlurred visionJaw claudicationPolymyalgia
Associated with RAOs
Emergency referral to Eye
Cas
ONLY
if visual symptoms
eg
.
Amaurosis
Otherwise refer urgently to Rheumatology / Physicians
Slide38GlaucomaOpen vs Closed angle1̊ vs
2
̊
Neovascular
What IOP is urgent?
<30mmHg refer to outpatients
>30mmHg D/W on call team
Slide39Acute Angle Closure GlaucomaTypically presents midday onwardsFixed, semi-dilated pupilHigh pressure, corneal oedemaClosed angle – may need to examine fellow eyeEmergency referral
Needs medical treatment then laser
iridotomy
More extensive surgery may be necessary
Slide40Vitreo & Medical RetinaPosterior Vitreous DetachmentVitreous haemorrhageRetinal tears and holesRetinal detachmentWet
AMD
Vascular occlusions
Proliferative diabetic
retinopathy
Slide41Posterior Vitreous DetachmentOnly 30-50% PVD symptomaticSymptomatic PVD refer to UCC, depending on durationMost are not associated with retinal detachment
Slide42Vitreous HaemorrhageCheck for systemic associations eg. DM, HT, SickleExamine fellow eye If present, UCC referral (duration dependent)
In
absence of systemic disease, PVD with VH has
70
% incidence of retinal tear
Urgent referral to Eye Cas
Slide43Retinal DetachmentIs the macula on or off? VA Clinical examIf on, emergency referralIf
off, Eye Cas, UCC or clinic depending on duration
Check
for
symptoms of
chronicity
Not all detachments are an emergency
!
Slide44Wet Macular DegenerationSudden onset reduction of vision, distortionH/O dry AMDOptician can diagnoseFast track macular service
Slide45Venous OcclusionsNo emergency treatment availableRefer via fast track systemNeed long term treatment
Slide46Arterial OcclusionsIrreversible retinal damage from 4hrs of onsetImmediate emergency treatment up to 8hrs from onsetAspirin
ocular
massage
rebreathing
into bag
Beyond this time no heroic measures
Check
for GCA symptoms
Stroke/TIA pathway
Slide47Proliferative RetinopathyMost commonly diabeticsAlso Sickle, prior RVOs and rarely RAOsRefer to UCC unless also VH
Slide48The Future6-9% annual increase in demand<30% of attenders are genuine 4hr casesPEARS / MECSRapid access clinicsAllied professionals in house
Nurses
Optometrists
Orthoptists
GP surgeries open all hours!