Eye Essentials For General Practice Davina Sehgal

Presentation Content Brief introduction Common ocular symptoms 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 Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches

Red Eye

Red Eye 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 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 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 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 Red Eye Itchy & Watery Eye Reduced Vision (Sudden or Gradual) Flashing Lights / Floaters Headaches

Reduced Vision (Sudden or Gradual)

Reduced Vision (Sudden) 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 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!!)  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 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: 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 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