Ophthalmology

1. Ophthalmology 01.11.2011

2. Plan of Talk • Context • History • Examination • Common presentations • Management • Referral guidelines Eye cases with Sarah

3. Not covered • Glaucoma • Uveitis • Diabetic retinopathy • Hypertensive retinopathy • Cataract • Macular degeneration • Dry eye • (Epi)scleritis

4. Context • Eye complaints are common in general practice1.5% of all consultations1 • GP ideally placed to triage – what can be reassured and what needs referral 1) SHELDRICK JH, WILSON AD, VERNON SA, SHELDRICK CM. Management of ophthalmic disease in general practice Br J Gen Pract1993; 43(376): 459–62

5. Anatomy of Eye

6. History • As with every system in medicine …! • Speed of onset • Pain • Redness • Laterality • PHx • Trauma/injury • medicolegal context!

7. Tools • Snellen chart • Pinhole • Torch with blue filter • Fluorescein • Red pin • Drugs • Topical anaesthetic • Proxymetacaine • Topical mydriatic • Tropicamide (short-acting) • Cyclopentolate • Ophthalmoscope

8. Snellen chart • Distant visual acuity with glasses • Pinhole improves visual acuity • Suggests refractive error • Ok to use topical anaesthetic if pain causing severe blepharospasm

9. What is DVLA requirement for driving in UK? • Group 1: corrected binocular V.A. >6/10 • Group 2: • corrected V.A >6/9 in better eye & >6/12 in worst eye • uncorrected V.A. of at least 3/60 • Visual field defects – if encroaching on fixation likely to be disqualified from driving

10. The anterior segmenteverything in front of the vitreous

11. Direct Ophthalmoscopy • Set the scene • Dim room lights • Ask patient to fix their gaze at a distant object to allow pupil to be dilated/tropicamide • Stand on patient’s right side to look at right eye • Select “0” on lens disc and have large aperture • Start from ~15 cm in front and slightly tothe right (250) of the patient and direct the light beam into the pupil • Red Reflex should appear as you look through the pupil

12. Anterior segment – What might you find? • Red reflex • Absence indicative of cataract/scarred cornea • Establish location of opacity by moving from side to side • Anterior segment (cornea/anterior chamber) opacity moves away from you • Plane of pupil (lens) remains stationary • Posterior segment (posterior lens/vitreous) opacity moves with you

13. Anterior segment – What might you find? • Lid swelling • Conjunctivitis • Chemosis • Blepharitis

14. Anterior segment – What might you find? • Ciliary injection (=redness around cornea seen in iritis & corneal problems) • Hypopyon • Posterior synechiae

15. Anterior segment – What might you find? • Corneal ulcers/FB

16. Anterior segment – What might you find? • Consider corneal reflex

17. Anterior segment – What might you find? • Cornea clear or cloudy which impairs view of iris (acute glaucoma)

18. Anterior segment – What might you find? • Fluorescein: Corneal defect appears green with blue light (check no contact lenses – stains!)

19. Anterior segment – What might you find? • Eversion of upper eye lid ?subtarsal FB – look down & evert lid against a cotton bud

20. Summary: Anterior segment – What might you find? • Red reflex • Lid swelling • Conjunctivitis • Ciliary injection • Corneal ulcers/FB • Consider corneal reflex • Cornea clear or cloudy • Epithelial defect with fluorescein • Subtarsal FB

21. Blurred vision • Examination as before but also: • Visual fields • Pupillary reaction to light • Swinging light test

22. Visual field examination Assess four quadrants by confrontation

23. Pupillary light reaction Pupils should react to light directly and consensually

24. Swinging light reflex Shine light into one eyeand then the other: • Normal:pupils remain constricted on both sides • RAPD =Marcus Gunn Pupil • suggestive of sensory defect: pupil dilates, this indicates asignificant retinal problem or optic nerve dysfunction

25. Blurred vision – Posterior segment examination • Dilate pupil with tropicamide for best results (warn pt re driving!) • Fundoscopy • Optic disc • Blood vessels • Macula • periphery

26. Direct ophthalmoscopy • Keep red reflex in view • Slowly move toward patient • Optic disc should come into viewwhen you are about 3-5cm from patient • If notfocused clearly, rotate lenses until the optic disc isas clearly visible as possible • The hypermetropic eye requires more plus lenses for clear focus of the fundus; the myopic eye requires minus lenses for clear focus

27. Fundoscopy – What are you looking for? • Disc • Clarity of outline • Colour • Elevation • Conditionof the vessels • Follow each vessel as far to the periphery as you can • Macula “look at the light” • Look for abnormalities in the macula area The red-free filter facilitatesviewing of the centre of the macula

28. Fundoscopy findings in visual loss • Disc swelling • seen in • anterior ischaemic optic neuropathy • central retinal vein occlusion • Vessel tortuosity and dilatation • seen in central retinal vein occlusion • Vessel narrowing • seen in central retinal artery occlusion • Retina • paleness in retinal artery occlusion • haemorrhages • retinal vein occlusion • diabetic retinopathy

29. Fundoscopy – The Periphery • “look up” for superior retina • “look down” for inferior retina • “look temporally” for temporal retina • “look nasally” for nasal retina

30. Direct ophthalmoscope Limitations • Media need to be clear ie difficult to view if corneal, lens or vitreous opacities

31. Direct ophthalmoscope -Limitations In patients with sudden onset floaters +/- retinal haemorrhages, direct ophthalmoscope may not give enough periphery view to locate peripheral tear or hole =>best refer

32. Tips for better fundal view • Corneal reflection can interfere with fundal view, suggest • use polarized filter (not on all) ophthalmoscopes • small aperture (reduces area of illuminated fundus) • direct the light toward the edge of pupil • Small pupil especially in the elderly • Use short acting dilating drops • most effective combination is tropicamide 1% and phenylepherine 2.5% • act on different parts of iris • If you can only use one dilating drop, instil tropicamide which dilates the pupil more efficiently than phenylepherine

33. Guidelines for ocular referralsImmediate • Non-traumatic red eye • Acute glaucoma • Painful eye after cataract op • Traumatic red eye • Chemical burn • Corneal laceration • Globe perforation • Sudden visual loss • Giant cell arteritis • Retinal artery occlusion (if visual loss is less than 6 hrs) • Any visual loss of less than 6 hrs ?cause • Third nerve palsy with dilated pupil

34. Guidelines for ocular referralsSame day • Red eye • iritis • Corneal infection • Trauma • Blunt trauma • Corneal abrasion • Foreign body • Swollen lids • Herpes zoster with ocular involvement – Hutchinson’s sign • Orbital cellulitis • Sudden visual loss • Vitreous haemorrhage • Sudden visual loss of more than 6 hrs • Sudden onset floaters • Retinal detachment

35. Guidelines for ocular referrals Same week or not at all • Same week • Persistent conjunctivitis • Episcleritis • Facial nerve palsy • Unless there is severe corneal exposure then within 24hrs • No referral needed • Painless sticky eye of less than 24 hrs • Chalazion

36. Non-traumatic red eye • Painful +/- blurred vision • Likely sight-threatening eg acute glaucoma, corneal infection, iritis • Painless + normal vision • Likely not sight-threatening eg conjunctivitis, episcleritis, subconjunctival haemorrhage HistoryExamination ?contact lens wearer (?corneal ulcer) Snellen chart – reduced vision= red flag ?sticky discharge (infective conjunctivitis) anterior segment PHx uveitis conjunctival injection(conjunctivitits) Bilateral itching (allergic conjunctivitis) corneal opacity pupil reaction to light (fixed in glaucoma & iritis)

37. Common causes - Swollen lids Chalazion Orbital cellulitis Herpes zoster • Due to reactivation of herpes zoster virus • Eye affected in 50% of zoster ophthalmicus and increased in patients with involvement of nasociliary nerve (rash at the tip of the nose) Acute dacrocystitis • Inflammation of lacrimal sac • often associated with obstruction of nasolacrimal duct with watering of eye • Infection often due to streptococcus andstaphylococcus • may require dacryocystorhinostomy after treatment of infection to prevent recurrence

38. Presentation redness, swelling, and pain in eyelid +/- conjunctivitis and purulent discharge Examination swelling may be at base of eyelash (stye = external hordeolum) or deep within lid (meibomianitis = internal hordeolum) Visual acuity normal unless big swelling and centering on upper lid => vision distorted due to mass effect on cornea ChalazionSecondary to blocked/superinfected eyelid glands

39. Chalazion Management • Usually self-limiting with conservative measures1 • 4 wks hot compresses • Resolution rates between 46% - 77% • Topical antibiotic (g. chloramphenicol qds) • No evidence! • If severe/extensive lid swelling, consider superimposed orbital cellulitis which requires systemic antibiotics • Refer to minor operating list if swelling fails to resolve after six months2 • mostly seen in internal hordeolum in which a granuloma develops • incision and currettage • Lederman, C. and Miller, M. (1999) Hordeola and chalazia. Pediatrics in Review 20(8), 283-284. • Cottrell, D.G., Bosanquet, R.C. and Fawcett, I.M. (1983) Chalazions: the frequency of spontaneous resolution. British Medical Journal 287(6405), 1595.

40. Orbital cellulitis • In adults due to Staph. aureus, Pneumococcus infection • In children due to secondary sinus infection and H. influenzae • Presentation • Severe pain • Tense and red orbit with lid closure • Pyrexia • Examination • Intense swelling of the lids • Proptosis • Congestion of the conjunctival and episcleral vessels • Chemosis (swollen conjunctiva) • Double vision may occur due to poor eye movement ina congested orbit

41. Orbital cellulitis • Treatment: • Treatment requires systemic antibiotics and analgesia • Refer to ophthalmologist within 24 hours – potentially sight threatening • Sight loss may result from central retinal artery occlusion or optic nerve inflammation or cavernous sinus thrombosis

42. Sudden painless visual loss • History • Transient “curtain coming down” – suggestive of amaurosis fugax • Visual loss or field loss preceded by sudden onset floaters and flashing light (photopsia) - suggestive of retinal detachment • Diabetic & retinal laser treatment – suggestive of vitreous haemorrhage • Headache +/- jaw claudication – suggestive of giant cell arteritis • Pain on eye movement in the young – suggestive of optic neuritis

43. Central/Branch Retinal Artery Occlusion Occlusion of retinal artery secondary to arteriosclerosis, embolus (from heart or Carotid artery) or inflammation (rare) History • Sudden painless visual loss • Complete -due to central retinal artery occlusion • partial -due to branch retinal artery occlusion • ?history of hypertension or heart disease or first presentation

44. Examination Visual acuity reduced in CRAO but may be normal in BRAO RAPD present in CRAO The retinal arteries are narrow or collapsed  In CRAO, the fovea shows a cherry-red spot against pale infarcted retina  In BRAO, the pale infarcted retina corresponds to the occluded retina  Emboli may be seen in the arteries if the cause is emboli Central/Branch Retinal Artery Occlusion

45. Central/Branch Retinal Artery Occlusion Management • Immediate referral if the visual loss is less than 6 hours • treatment may restore some/most of function  • Treatment involves iv acetazolamide and globe massage to lower intraocular pressure and hopefully re-establish arterial flow • Further management aims to uncover any underlying diseases such as hypertension, cardiac or carotid thrombus • ESR to exclude arteritic causes • Long term low dose aspirin is advised to reduce the risk of occurrence

46. Central/Branch Retinal Vein Occlusion Common vascular disorder caused by impaired venous blood flow.  Second most common vascular cause of impaired vision after diabetes. Presentation Sudden onset painless blurred vision Examination • Visual acuity reduced • Reduction dependent on severity of occlusion: Visualacuity may be normal in BRVO if fovea is not involved • Severe CRVO can produce RAPD • Fundoscopy: extensive intraretinal and pre-retinal haemorrhage with distendedretinal veins Management: • Refer within 24 hours • no immediate treatment to restore vision • but important toexamine for hypertension and glaucoma

47. Retinal detachment History: • Recent onset floaters and flashes of light common • “Curtain” coming across vision Examination: • Visual acuity variable depending if the macula is involved • Visual field defect • Fundoscopy shows greyish retina +/- hole and tear Management: • Refer same day • Patients will require surgical management which consists of sealing the retinal breaks(using cryotherapy or laser) and relieving the vitreous traction (using indentation or vitrectomy)

48. Ischaemic Optic Neuropathy • Due to occlusion of small arteries around optic disc • Need to differentiate arteritic optic neuropathy from non-arteritic optic neuropathy • Arteritic optic neuropathy due to giant cell arteritis is sight-threatening Presentation: • Sudden visual loss and history of persistent headache (temporal or occipital) or jaw claudication suggestive of giant cell arteritis

49. Ischaemic Optic Neuropathy • Examination: • Visual loss usually profound 6/60 or less in giant cell arteritis and less severe innon-arteritic ischaemic optic neuropathy • RAPD is common • In giant cell arteritis there is tenderness over the affected artery (usually the temporal artery)and the artery is usually not palpable • Fundoscopy reveals swollen optic disc caused by occlusion of the arteries aroundthe optic disc • Management: • Refer immediately any patient with sudden visual loss and swollen disc for exclusion ofgiant cell arteritis • ESR and CRP usually raised in giant cell arteritis but non-specific • definite diagnosis by temporal artery biopsy • Start high dose systemic steroid whilst awaiting biopsy

50. Optic Neuritis • Typically affects patients in the 20 - 45 age group • Presentation • Impaired vision • Central field defect • Slight pain on eye movement