Eyes

1. Eyes Dr Bruce Davies www.bradfordvts.co.uk

2. You are not alone! • A very popular topic • How much time at medical school? • What do the acuity numbers mean!

3. Special history • One or both? • What disturbance of vision? • Rate of onset? • Any blind spots? • Any associated symptoms e.g. floaters? flashing lights? • Exactly what is worrying the patient.

4. Contact lens use? • Myopia? (increases risk of retinal detachment 10 fold) • Any family history? (FH of glaucoma in a 1st degree relative gives you a 1/10 lifetime risk, or squint) • Any history of diabetes, hypertension or connective tissue disease?

5. Examination • Snellan chart, 3m or 6m, simple text for near vision, • Pinholes • Fields, remember red and the quality of the red, simple 4 quadrant testing. • Pupils: a bright torch and magnifying glass • Squint • Movements • Opthalmoscopy: Start at 10, red reflex?, green filter enhances blood vessels, dilate prn, risk of acute closed angle glaucoma remote.

6. Clinical classification • Red eye • Lids and tears • Slow visual loss in the quiet eye • Trauma • Squints, new and congenital, rare movement disorders • …..(then a rare specialist rag bag)

7. Red eye Conjunctivitis Commonest, an uncomfortable red eye. Bacterial • Discomfort. Purulent discharge. Spreads from one eye to the other. Vision normal. Uniform engorgement Chloramphenicol first choice (?)

8. Conjunctivitis Viral • Often with an URTI. Gritty. Discomfort. Watery discharge. May last many weeks. • Photophobia. Small corneal opacities may develop. Prolonged (often adenoviral) may need specialist therapy with steroids. Chloramphenicol to prevent 2nd infection.

9. Conjunctivitis Chlamydia • Mucopurulent, cornea inflamed, visual loss. Often with STD. Permanent damage possible, topical and? systemic tetracyclines. Refer. Infants • Less than one month is notifiable disease - any cause. May lead to scarring and permanent damage. Refer most. Allergic • Itching and discomfort. Chemosis and visual acuity loss possible. Papillae and if big cobblestones. Cromoglycate may take days to start to work if bad.

10. Episcleritis / scleritis Red sore eye. No discharge. Localised (viz. conjunctivitis=generalised) inflammation. • Episcleritis usually self limiting and idiopathic, no treatment needed. • Scleritis often with CT diseases, dangerous (perforation possible) Refer.

11. Corneal ulcers • Any infection, Abrasion, topical steroids, contact lens use. • PAIN. - Except zoster • May be general or localised inflammation. • Must stain. Should evert upper lid to exclude a sub tarsal FB • ?Hypopyon - pus in anterior chamber. • Refer most (except small abrasions - but refer if big or longer than 36 hours) • Remember recurrent abrasion syndrome.

12. Anterior uveitis • The uveal tract. So iritis, iridocyclitis and anterior uveitis are synonyms. • At risk: HLA-B27, CT diseases, past attacks, juvenile arthritis, sarcoid. • PAIN, then photophobia then visual loss. • Ciliary flush. As it gets worse the pupil gets small and reactions get sluggish, hypopyon, keratitis (back of cornea). These markers of it getting worse are bad news. • Refer all.

13. Acute closed angle glaucoma • Often starts in the evening. Especially in those over 50 years. • Severe pain first. Impaired vision and haloes around lights. May have history of past episodes relieved by going to sleep (the pupil constricts during sleep). • Refer even if attack spontaneously resolves.

14. Lids and tears Chalazion • = meibomnian cyst. In the lid. Warm compresses and chloramphenicol. Persistent - incise. • Recurrent: ? DM, ? blepharitis, ? roseacea. • Can cause astigmatism from pressure.

15. Stye • An infection of lash follicle. May be head of pus - nick with needle. Or warm compresses and chloramphenicol.

16. Marginal cysts • Non infected cysts from sweat or sebaceous lid glands, if a problem can often be simply treated with a nick with a needle - small.

17. Blepharitis • Common, underdiagnosed. Persistently sore eyes. Gritty. Often with chalazions or styes. Inflamed lid margins, crusts, may have inflamed lids. • Associated with psoriasis, eczema and roseacea. • Keep clean, antibiotic ointment[tetracycline], artificial tears ? oral tetracyclines

18. Acute dacrocystitis • Medial inflammation over lacrimal sac. Refer, systemic therapy and topical urgently.

19. Orbital cellulitis • Life threatening and blinding. Usually from sinuses. Especially important in children who may become blind in hours. • Unilateral swollen lids which may not be red. • The patient is ill, there is tenderness over the sinuses, restricted eye movements. ADMIT

20. Ectropion • Watery eye.. Laxity from age or nerve palsy. Ointment and refer for LA operation to correct. Entropion • Common especially in the elderly. Scarring from the lashes. • Often results from blepharitis or chronic conjunctivitis • Refer

21. Ingrowing lashes • Damage to lids. May be removed but will often need electrolysis or cryocautery to prevent recurrence.

22. Watering eyes • Differential diagnosis.- your homework! Dry eyes • Common, • Remember to treat associated blepharitis

23. Sudden visual loss An easy list really as they all need specialist assessment!

24. Retinal detachment • Floaters, photopsias, the shadow or curtain across the sight. Optic neuritis • More women, pain on moving the eye, central scotoma Posterior vitreous detachment • Aged 50+, flashing lights, floaters Vitreous haemorrhage • Floaters, red haze may be present. Red reflex absent.0

25. Disciform macular degeneration • Sudden disturbance of central vision. • Vascular occlusions • Field loss. Diabetes, hypertension • Migraine • Youth, headache, zigzag lines, multicoloured lights. • Cerebrovascular disease • Elderly, bilateral loss.

26. Slow visual loss Refer to optician then ? refer. • Cataracts • Corneal opacities • Macular problems • Retinal problems

27. Trauma • Refer ! • Unless really trivial

28. Squints • Refer • Remember the orthoptist • Can you do a cover test?