1. Eye Essentials For General Practice
Davina Sehgal

2. 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

3. 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

4. Common Ocular Symptoms
Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches

5. Red Eye

6. Red Eye Subconjunctival Haemorrhage Bacterial Conjunctivitis
Viral & Allergic Conjunctivitis
Iritis – Uveitis
Scleritis & Episcleritis
Foreign Body
Closed Angle Glaucoma

7. Subconjunctival Haemorrhage

8. 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

9. 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

10. 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

11. Viral Conjunctivitis

12. 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

13. 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)

14. Iritis – Uveitis
Can be associated with certain autoimmune disorders such as rheumatoid arthritis or ankylosing spondylitis
EMERGENCY!

15. 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

16. 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.

17. Scleritis
Topical non-steroidal anti-inflammatory drugs in symptomatic patients
Same day referral to eye hospital

18. 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

19. 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.

20. 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

21. Common Ocular Symptoms
Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches

22. Itchy & Watery Eye

23. 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

24. Common Ocular Symptoms
Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches

25. Reduced Vision (Sudden or Gradual)

26. 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

27. Reduced Vision (Gradual)
Cataract!!
Red reflex of ophthalmoscopy less bright
Nuclear, cortical, posterior subcapsular –different appearances
Age! Trauma, diabetes, medications such as steroids

28. Common Ocular Symptoms
Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches

29. Flashing Lights / Floaters

30. 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)

31. Retinal Tear / Detachment

32. Common Ocular Symptoms
Red Eye
Itchy & Watery Eye
Reduced Vision (Sudden or Gradual)
Flashing Lights / Floaters
Headaches

33. Headaches

34. 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!!

35. 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!

36. 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

37. 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). 

38. 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!!

39. Case Study 2
Px attends c/o headaches..., you check optic discs & find this:  
What does it mean?

40. Q&A

41. 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