Eye conditions the GP can manage or should recognise"

1. Eye conditions the GP can manage or should recognise" Mitch Menage Consultant Eye Surgeon Leeds Teaching Hospitals Trust GP Meeting March 2014

2. Blepharitis • Chronic inflammation of the lid margins • Common • Remitting • Range of ages • Bilateral • Often misdiagnosed as conjunctivitis

3. Blepharitis • Lid anatomy • Types • Associated conditions • Symptoms • Signs • Treatment

4. Lid anatomy Meibomian/tarsal glands Glands of Zeiss and Moll

5. Lid anatomy

6. Blepharitis-Types • Anterior –staphylococcal/dandruff • Yellow flakes on lid margin • Posterior sebborhoeic • Inflamed red oily lid edges

7. Blepharitis

8. Staphylococcal Blepharitis • More common young patients • Chronic infection of base of lashes • Staph. Aureus • Associated with styes • Secondary • Papillary conjunctivitis • Punctate corneal erosions • Marginal keratitis

9. Seborrhoeic Blepharitis • More common older patients • Excessive lipid secretion meibomian glands • Meibomitis/MGD • Lid commensals break down to free fatty acids • Shiny waxy lids with greasy lashes • Secondary • Papillary conjunctivitis • Punctate corneal erosions

10. Acne Rosacea • Strongly associated with seborrhoeic blepharitis • Mild forms not diagnosed

11. Blepharitis-Symptoms • Sore burning itching irritation of lids • Grittiness and watering • Mild stickiness particularly on waking • Red lid margins • Dry eyes

12. Signs • Red lid margins • Greasy material along margin of lids • Clogging of meibomian gland openings • Mild conjunctival injection • Punctate corneal staining • Acne Rosacea • Styes/chalazions

13. Chalazion

14. Treatment • Patient education! • Lid hygiene cotton buds/baby shampoo • Hot compresses • Warm flannel 5 mins • Eyebag • Lubricants • Antibiotic gel/ointments • Oral antibiotic Doxycycline/Limecycline • Intermittent steroid ointment

15. Eyebag www.eyebagcompany.com

16. Dry Eyes • Lacrimal apparatus • Tear Film • Causes/Associated Conditions • Symptoms • Signs • Treatment

17. Lacrimal anatomy

18. Tear film • Several layers • Lipid outer • Aqueous • Mucin inner • Quantity/Quality

19. Tear film

20. Causes of Dry Eye‘Keratoconjunctivitis Sicca’ • Lacrimal gland aging • Strongly associated with blepharitis • Inflammatory conditions • Rheumatoid arthritis • Sarcoidosis • Sjogrens Syndrome • Laser refractive surgery

21. Sjogren’s Syndrome

22. Sjogrens Syndrome • Very severe dry eyes • Middle-aged women • KCS/Xerostomia and vasculitic disease • Rheumatoid Arthritis • SLE • Scleroderma • Polyarteritis • Blood tests • ANA 70% • SSA(RO) 70% SSB (LA) 40% • RhF 60%

23. Symptoms • Feel dry (Can be watery!) • No relation to emotional tearing • Gritty burning eyes • Worsening through day peak in evening • Worsened by reading, TV, computer • Worsened by air conditioning, central heating, dry arid conditions

24. Signs • Often none! • Poor tear film on SL with rapid break-up time • Punctate staining of cornea inferiorly • Filament strands of mucus on cornea • Schirmers test

25. Signs Rapid tear break-up time

26. Signs Rose Bengal staining

27. Signs Mucus Filaments

28. Schirmers Test

29. Treatment - Lifestyle • Avoid dry situations • Car heater • Air conditioners • Irritants cigarette smoke etc. • Drugs BP, antidepressant, antihistamine etc • Increase humidity • Plants, wet towels, radiator trays etc. • Humidity chambers • Wraparound glasses • Swim goggles

30. Treatment-Lubricants • Liquid drops • Frequent application • Gels • More blurring • Ointments • Usually only at night • Nocturnal lagophthalmos • Preservative free?

31. Liquid Lubricants

32. Gel Lubricants

33. Ointments

34. Other Treatments

35. Treatment • Anti-inflammatory • Steroid • Cyclosporin –Restasis • Antimucolytic • acetylcysteine –Ilube • Oral pilocarpine-Salagen • Usually only in Sjogrens • Side effects/limited efficacy

36. Treatment • Punctal occlusion • Cautery • Plastic Plugs • Smartplugs

37. Punctal Cautery • Simple procedure under L/A • Often preceded by temporary trial occlusion • Cautery inserted into punctum/canaliculus • Sometimes not successful • Permanent and difficult to reverse • More common to use temporary plugs first

38. Punctal Plugs

39. Smartplugs

40. Age-Related Cataract • Definition • Symptoms • Examination • Common Clinical Types

41. Definition • Change in clarity of human lens • Commonly an ageing change – a normal degeneration throughout life • ‘Cataract’ – significant effect on vision • Often optometrist ‘unable to help with change of glasses’

42. Symptoms • Rapid change in spectacle prescription – myopic shift • Blurring near and distance • Glare • No pain, watering, redness

43. Examination • Competent visual acuity • Dilating drops • Direct Ophthalmoscope

44. Common Types • Nuclear sclerosis • Cortical • Posterior Subcapsular

45. Anatomy

46. Nuclear

47. Cortical

48. PSCLO

49. Acute Angle Closure(Glaucoma) • Incidence increases with age peak ~70 years • 0.1% incidence in UK Effect of cataract surgery • 3/4x commoner in females • Associated with hypermetropia (long sight) • Normally unilateral

50. Cause • Shallow anterior chamber with narrow angle • Pupil block • Angle occlusion with rapid severe elevation of IOP