The Unquiet Eye in General Practice

Session Aims Anatomy: Understand the anatomy and terminology History:What is a reasonable targeted eye history? Examination:What is reasonable targeted eye examination? Common causes of an unquiet eye: – recognition and management

Terminology: Perilimbic area - conjunctiva - sclera - cornea - iris - cilary body Palpebra = lid Kerat = cornea Phak = lens Uveal body anterior = iris & cilary posterior = choroid

Ophthalmic History HOPC Trauma (eye or head) Pain – discomfort through to photophobia Change in vision & visual disturbance Contact Lenses PMH – eye problems, CTDs, IBDs.

Ophthalmic Examination Full Ophthalmic Examination Acuity:RE & LEC & UCSnellen External eye: Inspection Fluorescein Internal eye: Pupil & iris Fundoscopy Other bits:FieldsColour visionEye movements]

Some causes of an unquiet eye

Posterior vitreous detachment Virtually universal, but it is linked with retinal detachment

Posterior vitreous detachment When is likely to be more serious? - trauma, very short-sighted get it younger When does it need referral? 85%A few floaters that go quicklyNormal, probably ignore but safety-net 10%Lots of floaters that persistConsider urgent referral 5%A couple of flashing lightsRetinal traction – urgent referral 1%Lots of flashing lightsLots of retinal traction – same day referral 0.1%StarburstRetinal tear – same day clinic 0.01%Loss of visionRetinal detachment – same day clinic Trauma? – probably move up one step

Blepharitis: Lid cleaning Chloramphenicol ointment if acute Link with seborrhoeic dermatitis Link with styes & chalazion Chalazia: – warm compress, refer after 4-6m

Bacterial Conjuctivitis: Purulent discharge & irritation No vision loss (smearing) No pain Sticky eye (not red) = leave Manky eye = treat No school exclusion Allergic bilateral, very itchy prominent papillae Viral bilateral, watery, irritated small papillae PAIN? = think cornea = refer

Nodular Episcleritis: Common (I see 2-3 per year) Uncomfortable Lasts 2-4 weeks Oral nsaid usually enough Often recurrent Refer if unusual Diffuse Episcleritis: Rarer (I see per decade) Uncomfortable to painful Associated with CTDs Refer as may be scleritis (looks the same)

Subconjunctival Haemorrhage: Common (I see 2-3 per year) Trauma or spontaneous [think BP & anti-coag] Uncomfortable Lasts 2-4 weeks Can look very alarming with a swollen and bulging conjunctiva

What makes you think cornea/ iris? Pain, pain, pain... Blurring of vision (if on visual axis) Must do acuity, must do fluorescein Corneal ulcers: Trauma (remember sub-tarsal FB) Bacterial (deep, punched) Viral (HSV, VZV, often irregular) Fungal (contact lens) Small traumatic abrasion – OK to watch Everything else - refer

And finally.... Iritis (anterior uveitis) Early – discomfort, vision OK, perilimbal flare Later – pain++, dropping acuity, very red Blurring of vision Iris & pupil Poor reaction, iris sticks to lens Anterior chamber Cloudy (exudate), hypopyon Contrast early iritis with conjunctivitis...

Key Messages Anatomy Understand the anatomy and terminology HistoryWhat is a reasonable targeted eye history? (Trauma, pain, vision change, contact lens) ExaminationWhat is reasonable targeted eye examination? (Acuity & Fluorescein) Mild versions can be very similar: episcleritis, viral conjunctivitis, iritis If in doubt, review in 24-48hrs.