Matt Edmunds Clinical Lecturer Specialty Registrar Academic Unit of Ophthalmology University of Birmingham What I have been asked to address 1 What is an acceptable GP eye examination pupils APD VA ID: 348693
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Slide1
Ophthalmology in Primary Care
Matt Edmunds
Clinical Lecturer / Specialty Registrar
Academic Unit of Ophthalmology
University of BirminghamSlide2
What I have been asked to address (1)
What is an acceptable GP eye examination: pupils/ APD/ VA/
fluorescein
/dilation or not - when is it acceptable to ask an optician to help before referral?
Any tips/ tricks other than practice for better
ophthalmoscopy
/
fundoscopy
?
What possible emergency/ urgent eye conditions do you think need:
Immediate referral/today/tomorrow morning/clinic?
How should we access these/ advice OOH? Slide3
What I have been asked to address (2)
The red eye
What to do about dry eyes/ watering eyes/
blepharitis
What to do about floaters and/ or flashes
What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage? Slide4
Question 1:
What is an acceptable GP eye examination: pupils/ APD/ VA/
fluorescein
/dilation or not - when is it acceptable to ask an optician to help before referral?
What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?
Slide5
Ophthalmology in primary care
Broad generalisation…
….
Most patients will present with ‘red eye’
Significant proportion of red eye can be managed in primary care
Whereas most ‘non-red eye’ pathology is likely to require secondary care input
Limitations
Not much training in eyes
Year 4
MBChB
at
UoB
: 5 days ophthalmology
Few GP VTS posts in ophthalmology across Midlands
Lack of equipment
Pressurised for time Slide6
History
Acute or gradual onset?
One or both eyes?
Is vision affected?
Discharge?
Purulent?
Watery?
Pain?
Sensitivity to light?
Contact lens wearer?
Previous episodes?
Industrial injury?
Associated systemic symptoms?Slide7
What we would hope for….
Visual acuity (and idea of any recent changes)
Pupil reactions
Eye movements
Gross observations
Lid swelling and discharge / lash crusting
Distribution of any redness / obvious eye lesions
Corneal staining with fluorescein / FB
Comment on anterior chamber / cornea
TIP: Ophthalmoscope on +20D
Optic disc / fundus
Not easy with ophthalmoscope
Please, at least trySlide8
Visual acuity testing
Can use book
eg
BNF/BMJ if
snellen
chart not available on wards
Snellen charts needed in practiceSlide9
How to tell a person’s refraction
Hypermetrope (convex)
Myope (concave)
Almost emmetropicSlide10
Visual acuity testing
If unable
to read top line on
Snellen
chart:Slide11
Visual acuity testing
If unable
to read top line on
Snellen
chart:
Count fingers? (CF)Slide12
Visual acuity testing
If unable
to read top line on
Snellen
chart:
Count fingers? (CF)
Hand movements? (HM)Slide13
Visual acuity testing
If unable
to read top line on
Snellen
chart:
Count fingers? (CF)
Hand movements? (HM)
Perceive light? (PL)Slide14
Visual acuity testing
If unable
to read top line on
Snellen
chart:
Count fingers? (CF)
Hand movements? (HM)
Perceive light? (PL)
No light perception (NLP)Slide15
Apologies!
Conjunctiva
Limbus
Iris
Cornea
Lower
punctum
Upper
punctum
CaruncleSlide16
Over the phone
Temporal
Nasal
Superior
Inferior
12
6
9
3Slide17
Question 2:
Any tips/ tricks other than practice for better
ophthalmoscopy
/
fundoscopy
?
Dark room
Dim ophthalmoscope light
Smaller pupil setting
Get patient to look into distance
?Pharmacologically dilate pupils
Mainly: have low expectations!Slide18
Question 3:
What possible emergency/ urgent eye conditions do you think need:
Immediate referral/today/tomorrow morning/clinic?
How should we access these/ advice OOH?Slide19
Key things to remember
There may be disparity in sense of urgency
You may get a different response to a referral at different times of the day –
appropriate
Please don’t ‘opt out’ of ophthalmology
Please always send a brief referral letterSlide20
Guidelines for Referrals
Same day
Acute glaucoma
Temporal
arteritis
(with definite ophthalmic symptoms)
Painful eye after cataract
surgery
Painful or red eye after corneal graft
Painful or red eye in contact lens wearer
Orbital
cellulitis
Suspected corneal infections
Could wait until next day
Uveitis
Zoster with eye involvement
Scleritis
If not resolving as expected
Conjunctivitis
Episcleritis
Via out-patient clinic
Blepharitis
/ Dry eye / Chronic grittiness or soreness
Entropion
EctropionSlide21
I will see overnight…
GCA with eye involvement
Temporal pain / jaw claudication / night sweats / weight loss / transient visual
obscurations
/ visual disturbance
CRAO within past 24 hours
Sudden and persistent unilateral painless loss of vision
Orbital cellulitis
Significant chemical injury
Suspected penetrating eye injury / significant trauma
Retrobulbar
haemorrhage
Acute glaucoma
Suspected
endophthalmitis
Painful red eye / reduced vision / recent intra-ocular interventionSlide22
Can wait until tomorrow morning…
Suspected retinal tear / detachment
Suspected vitreous haemorrhage
Suspected optic neuritis (unless GCA)
New onset
diplopia
Unless 3
rd
nerve palsy / complex CN palsy
Most trauma
Most red eye pathologySlide23
BMEC Eye Casualty
Open for walk-in patients 365 days / year
No referral necessary
Accept all patients 9am – 7pm Mon-Sat / 9am-6pm Sun and Bank Holidays
Urgent care clinic available via triage nurse
Also have acute referral clinics at RHH / SGH
Limited number of clinic slots
Accept direct GP referrals
No emergency eye clinic at QEHSlide24
OOH
On-call registrar via telephone overnight
Discuss emergency patients
Review patients on eye ward if necessary (Sheldon Block, City Hospital, Dudley Road)
Senior
SpR
(4
th
on-call) will review patients in peripheral units if necessarySlide25
If in doubt
Contact triage nurse at BMEC
Call on-call
SpR
(2
nd
or 4
th
on-call) at BMEC
Send to BMEC eye casualty
With a letter
If patient will arrive before closing time (7pm)Slide26
Question 4:
The red eye!
What to do about dry eyes/ watering eyes/
blepharitis
Slide27
Red Eyes
Up to 80% of eye casualties present with a red eye
Causes of a red eye can be roughly divided into two groups
Pain +/- blurring of vision
No pain and normal visionSlide28
Common pathology is common!
Most red eyes are due to conjunctivitis /
blepharitis
/ dry eye
If you can confidently exclude ‘serious’ pathology
Oc. Chloramphenicol 1.0% QDS
Warm compresses
Lid hygiene
Lubricants PRN
Celluvisc
/
Optive
/
Systane
/
Hyloforte
/
Xailin
Olapatidine
BD (
Opatanol
) for allergic disease
Discuss / refer if not improving / resolvingSlide29
Pain +/- blurred vision
Important differential diagnoses include:
Acute glaucoma
Corneal infections
Anterior
uveitis (
iritis
)
Scleritis
No pain
Differential diagnoses include:
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
Red EyesSlide30
Causes
Eyelids
Conjunctivitis
Bacterial
Viral
Chlamydial
Allergic
Keratitis
Bacterial
(Marginal)
Viral
(
Episcleritis
) /
scleritis
Acute anterior
uveitis
(
iritis
)
Angle closure glaucoma
Orbit
Orbital cellulitis
Trauma
Subconjunctival
haemorrhage
Corneal abrasion Corneal FBChemical burnSlide31
BlepharitisSlide32Slide33
Blepharitis – Treatment
Lid hygiene
Warm compresses
Gentle expression of lipids with a cotton tipped applicator
Gentle lid cleaning with a solution of sodium bicarbonate
Antibiotic ointment
Lubricants
Omega-3
Low dose
tetracyclines
Antibiotics
Lipid soluble
Protease inhibitorsSlide34
Stye
Infected hair follicleSlide35
Chalazion
Blocked
meibomian
glandSlide36
Entropion
Ectropion
In-turning of the lower lid
Out-turning of the lower lidSlide37
Herpes zoster
ophthalmicus
S
hinglesSlide38
ConjunctivitisSlide39
Bacterial conjunctivitisSlide40
Bacterial conjunctivitisSlide41
Bacterial conjunctivitisSlide42
Viral conjunctivitisSlide43
Viral conjunctivitis examinationSlide44
Viral conjunctivitisSlide45
Chlamydial
conjunctivitis
“
Unilateral red eye in a young male
”Slide46
Allergic conjunctivitisSlide47
KeratitisSlide48
Bacterial keratitis
Bacterial infection of the corneaSlide49
Clinical FeaturesSlide50
Clinical FeaturesSlide51
Clinical FeaturesSlide52
Bacterial keratitis treatmentSlide53
Viral keratitis
Viral infection of the corneaSlide54
Herpes simplex keratitisSlide55
Viral keratitisSlide56
ScleritisSlide57
ScleritisSlide58
ScleritisSlide59
ExaminationSlide60
TreatmentSlide61
Intraocular inflamationSlide62
Acute anterior uveitis (
iritis
)
Inflammation of the irisSlide63
ExaminationSlide64
ExaminationSlide65
Acute anterior uveitis (iritis)Slide66
Acute angle closure glaucomaSlide67
Acute angle closure glaucomaSlide68
Acute angle closure glaucoma
Palpate the eye to approximate IOPSlide69
Question 5:
What to do about floaters
/ flashing lights
Don’t panic
–
most cases will be a PVD
Could it be migraine??
If there is a retinal detachment
–
at BMEC:
‘Macula on’
–
24-48 hours
‘Macula off’
–
5-7 daysSlide70
‘Macula On’ versus ‘Macula Off’Slide71
‘Macula On’ versus ‘Macula Off’Slide72
Other important conditions…..Slide73
Temporal arteritisSlide74
Orbital cellulitisSlide75
Orbital cellulitisSlide76
Under active ophthalmic reviewSlide77
Sudden, painless visual lossSlide78
Please do not refer (if spontaneous
)Slide79
Quiz
At 5 pm on a Thursday afternoon
…….
68 year-old woman
Previous right eye retinal detachment
2 days history of left flashing lights / floaters
Right VA 6/36, Left VA 6/9
Pupil reactions normalSlide80
At 11 am on a Friday morning
…….
76 year-old woman
Hypermetrope
‘Optician says I have cataracts in both eyes’
2 months intermittent left eye pain, redness and hazy vision
Right VA 6/12, Left VA 6/24
Pupil reactions normal
Quiz Slide81
At 9 am on a Monday morning
…….
26 year-old man
Awoke this morning with a painful, red left eye
‘Short-sighted’
Slept in contact lenses overnight from Saturday
Right VA 6/12, Left VA 6/18 (wearing old specs)
Pupil reactions normal
Quiz Slide82
At 2 pm on a Monday afternoon
…….
26 year-old man
1 week history of red, gritty eyes and discharge
Partner had sore throat and ‘flu symptoms
Baby daughter recently had red eyes
Right VA 6/9, Left VA 6/9
Pupil reactions normal
Quiz Slide83
At 6 pm on a Tuesday afternoon
…….
36 year-old man
Recent nose bleeds and short of breath
Difficulty with left hearing
Past 3 days unable to sleep with painful, red right eye and some photophobia
No response with
paracetamol
/ibuprofen
Right VA 6/12, Left VA 6/9
Pupil reactions normal
Quiz Slide84
At 10 am on a Tuesday morning
…….
76 year-old woman
Feeling generally unwell, off food, losing weight, difficulty sleeping
Night sweats 2 weeks
Headache
Right VA 6/9, Left VA 6/9
Pupil reactions normal
Quiz Slide85
Key Points
Purulent discharge =
bacterial infection
Photophobia =
keratitis
,
uveitis
Reduced vision =
keratitis
,
uveitis
, angle closure glaucoma
Pain =
scleritis
, angle closure glaucoma,
keratitis
,
uveitis
Hazy cornea =
angle closure glaucoma,
keratitis
,
uveitis
Contact lens wearer and sticky eye =
must exclude bacterial
keratitisSlide86
In summary: easy ‘rules of thumb’
VA and pupil examination are
crucial
Refer
any
CL wearer with red eye or pain
Become familiar with a limited range of lubricant drops and stick to them
If giving drops >4x/day then they should be PF (preservative free)Slide87
In summary: easy ‘rules of thumb’
Please don’t prescribe ocular topical steroids in primary care
–
great potential for ‘disaster’
Please do provide topical steroids if ongoing eye review
Squinting children
Recent onset: refer urgently to eye
cas
Long-standing: refer to clinic
Temporal
arteritis
No visual symptoms
–
refer to rheumatology
Visual symptoms
–
refer to ophthalmology