Idiot’s guide to eye problems Cass Adamson January 2011

What do GPs need to know? Many conditions Wealth of info GP books short chapters Serious consequences if wrong There are hundreds of eye conditions, and considerably more information about them all available. What do we actually need to know? Most GP text books have surprisingly short chapters on ophthalmology. Suggests we don’t need to know specifics or details about most conditions. Patients present with symptoms – we need to be able to quickly and simply identify whether serious problem or not through just history and a basic eye examination. Actually need to know investigations and management of a handful of problems, the rest will be seen by optician, ophthalmologist or other professional (eg neuro) and we can continue management.

Take home message: If in doubt – REFER!!! Golden nugget

Session plan: Presentation on assessing and managing common or serious eye problems Videos on eye examinations (optional) Practical session for practising fundoscopy and other eye examinations CSA practise Tried to adopt very simplistic approach – does anything need doing? If so, what? Not covering red or itchy eyes/eyelid probs as most e-learning modules and GP targeted info seems to cover these

Eye assessment External examination of eyes and face Visual acuity Visual fields Pupils + swinging torch test Fundoscopy Eye movements With these simple assessments most decisions can be made regarding possible cause and management

“There’s something in my eye” Joan Peters 65 Controlled hypertension 5/7 ago sudden appearance of ‘tadpole’ in L eye with some flashing lights. No trauma Vision NAD Symptoms started whilst watching TV. Also noticed a brief black shadow edge of lateral vision L eye. Flashes resolved but ‘tadpole’ still there. Thought it would ‘go away’. Wears glasses but no change Vision – last check 1 year ago, not had glasses changed for years

BP 148/79 Eyes appear normal PEARL Eye movements NAD Fields NAD VA (with glasses) R – 6/5 L – 6/6 Fundoscopy: Feels well in herself. No recent illness. Fundoscopy – retina nad, but floater seen ‘swimming’

What do you do? Reassure her Advise optician r/v Ask about foreign travel and explain that the ‘tadpole’ could be a worm Refer routinely Refer urgently Refer immediately

Posterior vitreous detachment - normal examination - Floater black ‘cobweb’ or ‘curtain’ But new flashes and floaters are retinal detachment or retinal tears until proven otherwise. → refer urgently Most common cause – PVD which is common later middle ages and benign – vitreous jelly breaks into solid and liquid parts and the solid part peels off retina. Cannot exclude retinal detachment with ophthalmoscope hence need referral for thorough examination and assessment. Typically vision and fields normal, pupils normal, no RAPD.

Retinal detachment Rhegmatogenous or traction. Flashes, floaters and field loss – curtain from periphery Blurred central vision Often notice a shadow or ‘curtain’ peripheral vision as well as flashes and floaters. Increased risk if myopic (short sighted). Rhegmatogenous – tear in retina, fluid behind strips retina forward. Usually progresses peripheral tear towards macula. Takes hours-days usually. Traction – abnormal blood vessels in proliferative diabetic retinopathy pull retina off. If macula unaffected visual acuity may be normal, but might see RAPD or field defect

Retinal tear Vitreous haemorrhage Flashes and floaters Floaters large and red or black Tearing or bleeding Floating blobs or severe visual loss Floaters might be large and red or black if tear has caused vitreous haemorrhage. Vitreous haemorrhage caused y normal vessels tearing eg retinal tear or abnormal vessels bleeding eg prolif diabetic retinopathy. Or trauma. If haemorrhage only and no retinal detachment, will not see RAPD. Visual acuity normal or reduced. Decreased or absent red reflex if severe. Haemorrhage more common with diabetes.

“It’s double vision, Doc” Hanif Khan 47 Occasional headaches Last night sudden onset diplopia and a headache which is worsening. Taken some ibuprofen, partial relief Consulted with headaches few times previously. No other PMH. No vomiting. Doesn’t feel quite right.

L eye looking down and outwards Unable to look up, down or medially Partial ptosis L pupil slightly dilated and less reactive to light

What do you do? Inform him it is a CN III palsy and to come back if his symptoms worsen Prescribe analgesia for headache Ask optician to examine fundi then r/v patient Refer routinely Refer urgently Refer immediately

New sudden onset diplopia adult has a life threatening cause eg aneurysm until proven otherwise → immediate referral Gradual onset diplopia in adult can be tumour. Can see transient or persisting diplopia with temporal arteritis

Causes of diplopia: Intoxication Head injury CVA Orbital floor # Guillain-Barre Myasthenia gravis Early cataract CN III, IV, VI palsies Other signs to look for: Enlarged pupil, ↓ response light – CN III palsy Ptosis – CN III palsy or MG Lid retraction – thyroid eye disease Red eye – thyroid eye disease or orbital inflammation Ocular torticollis – CN IV palsy Check they mean diplopia and not blurred vision. Thankfully not common in GP, but A&E admit many people for overnight observation as cannot exclude serious cause until sober. Orbital floor # - difficulty looking up CN III and VI most common. VIth palsy – horiontal diplopia and unable to look laterally affected side. IVth palsy – vertical or oblique diplopia. Can be very difficult to detect clinically – often need to use cover test. Pt may have a head tilt to the opposite side.

Blurred vision: Serious eye/brain disease likely if signs: Red eye Visual field defect RAPD Abnormal cornea, iris or pupil Loss red reflex Optic disc swelling or pallor Serious eye/brain disease likely if symptoms: Unexplained eye pain Photophobia Distortion vision Flashes of light New floaters Loss part visual field Sx temporal arteritis

“ I can’t see in my left eye!” Hannah Cook 76 Type 2 diabetes and hypertension This morning sudden reduced vision L eye Mildly painful DH: bendroflumethiazide, metformin, simvastatin and aspirin

BP 156/66 Last HbA1c 7.9% VA (with glasses) R – 6/9 L – 6/18 Eye movements NAD Possible RAPD Fundoscopy:

What is it? Linked with hypertension, diabetes and chronic glaucoma. Consider hypercoaguable state eg myeloma.

What do you do? Review her medications and add in a further agent for BP and DM Make sure she sees her optician soon as her glasses are clearly inadequate Refer routinely Refer urgently Refer immediately No treatment for it though. Important to reduce CV and coagulation risks. Ophthalmology will observe and if new vessels, laser photocoagulation therapy.

Central retinal vein occlusion: Widespread retinal haemorrhage Tortuous dilated veins Macular oedema Optic disc swelling +/- cotton wool spots. Proliferative Diabetic Retinopathy: Cotton wool spots Hard exudates Dot and flame haemorrhages Optic disc swelling in one eye suggests disease within eye, not raised ICP

Branch retinal vein occlusion: Appearance similar to CRVO Sx: sudden blurring or field defect Central retinal artery occlusion: Sudden painless loss all vision ↓↓↓ VA (light only), RAPD Pale retina, cherry red macula But distribution shows branch Pt has sudden blurring of vision and/or partial visual field defect. CRAO – loss vision ONE eye. Usually caused by atherosclerotic clot, also linked temporal arteritis, hypertension, and DM. Needs immediate referral (for reduction IOP within hours to prevent further visual loss). Branch retinal artery occlusion – sudden painless loss section of visual field and/or blurring central vision. Usually secondary to stenosed carotid artery. See sectoral retinal pallor, reduced VA and/or visual field defects

Transient visual loss: ONE BOTH

Sudden or rapid visual loss: ONE BOTH If the eye is red, separate assessment ARMD = age related macular degeneration Bilat acute optic neuropathy – eg temp arteritis YES NO

Gradual visual loss: NO YES If the eye is red, separate assessment

“My eyes keep going funny” Jemima Duck 26 Had headache past 3/52. 4/7 when bending forwards nausea and transient visual loss BMI 29.6 Takes COCP No PMH

?RAPD (subtle) Eye movements NAD VA L - 6/9 R – 6/12 Fields - ?central scotoma Fundoscopy (bilateral):

What do you do? Refer for routine CT/MRI head Refer for urgent CT/MRI head Call 999 Admit medical team Refer to ophthalmology routinely Refer to ophthalmology urgently Needs urgent imaging to exclude intracranial pathology. If clinically well and able to arrange scan soon, could arrange urgent imaging then refer to appropriate team. She has urgent CT scan – NAD. What is the diagnosis? BIH is raised ICP in absence intracranial in absence mass lesion or hydrocephalous – more common younger females, COCP, obesity, smokers. In women it may coincide with recent weight gain, fluid retention, the first trimester of pregnancy and the postpartum period. Often idiopathic. Due to reduced absorption CSF by arachnoid villi.

Papilloedema: Unilateral – disease within eye Bilateral - ↑ICP Raised ICP – brain tumour, traumatic brain oedema, intracranial haemorrhage. Also severe acute hypertension Any cause of acute or chronic optic neuropathy – eg anterior ischaemic optic neuropathy sec to atherosclerosis or temp arteritis, MS, infectious optic neuritis, infiltration optic nerve by sarcoid or tumour, B12 deficiency. Photos – L to R – mild to severe papilloedema then chronic changes. Initially disc ‘disappears’ then swelling seen and finally appears distorted.

“My eye is droopy” Bob Smith 54 year old smoker. 5/7 drooping L eyelid, worsening Otherwise asymptomatic L eyelid partial ptosis, L pupil smaller. Light response: constricts briskly light, poor dilation dark

Possibly some weight loss Longstanding mild dry cough Probable Pancoast’s Syndrome Other causes: Head or neck trauma Brainstem stroke Dissecting internal carotid aneurysm Pancoast’s syndrome = Horner’s syndrome secondary to pancoast’s tumour (Apical lung tumour) Ptosis – age related (aponeurotic) due to stretching and thinning of levator muscles most common – usually see bilat ptosis but one eye is worse. Other cause of bilat is MG. Unilat more likely to be CN III palsy or Horner’s.

Approach to ptosis: Bilateral: age related or MG Mild: Horner’s syndrome Double vision or limited eye movements: MG or CN III palsy Pupil small: Horner’s Pupil large: CN III palsy Fatigability: MG →refer Unilateral = any cause Moderate or severe = any cause Refer to exclude serious underlying cause.

“My eye looks odd” Sarah Brown 19yr. Her mother noticed her R eye looked ‘odd’ this morning. Recent bad cold. No PMH Takes COCP

Unilateral dilated pupil Poor or no response light. Adie’s pupil Unilateral dilated pupil Poor or no response light. Usually unilateral dilated pupil due to paralysed iris sphincter secondary to lack of parasympathetic supply. Unknown cause but possibly follows viral infection. Resolves spontaneously with time.

Unequal pupils: YES NO YES YES NO NO

More words of wisdom: Not all flashing lights with headache are migraine Blurred vision or headache needs field test Field loss always needs assessment Sudden onset visual distortion – urgent ref Consider temporal arteritis every pt >50 with headache or visual change The TAKE HOME MESSAGES Occipital tumours and vertebrobasilar TIA can present with flashes too. Field testing may be only way to detect tumour eg pituitary. Urgent assessment if field loss sudden or visual pathway disease suspected. Sudden visual changes likely to be acute macular disease – needs urgent referral. Consider temp arteritis >50 with transient or persisting vision loss or double vision. New headache, scalp tenderness, jaw ache on chewing, ear or neck pain, weight loss, fatigue, muscle aches. Temporal arteries that are tender to palpate and/or not pulsatile. Urgent ref is suspect.

Red eye with decreased vision, pain or photophobia needs same day referral. Any child with a turned eye has sight/life threatening condition unless disproved New onset flashes and floaters are retinal detachment until proven otherwise Childhood tumours of the brain and eye often present with a turned eye. Plus, they rarely ‘grow out’ of strabismus – delayed treatment can cause permanent visual loss.

References: 1. Pulse Plus – Ophthalmology 2. Pulse – Picture quiz: Acute Referrals to Ophthalmology 3. Practical Ophthalmology – A Survival Guide for Doctors and Optometrists (2005). A. Pane and P. Simcock 4. Symptom Sorter 4th ed (2010). K. Hopcroft and V. Forte 5. The 10-Minute Clinical Assessment (2010). K. Schroeder 6. Google images!

Funsdoscopy: http://www.heine.com/eng/INFO-CENTER/INFORMATION-LITERATURE/Filme-und-Neuheiten/Direct-Ophthalmoscopie