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GP Ophthalmology

GP Ophthalmology. 60 in 1000 consultations are for eye problems 1 or 2 consultations a day 10-15% of all “eye” consultations are for conjunctivitis. Commonest Problems referred to Eye Casualty. 1/. Persistent red eye or unresolving conjunctivitis 2/. Corneal FBs/ Corneal abrasions

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GP Ophthalmology

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  1. GP Ophthalmology 60 in 1000 consultations are for eye problems 1 or 2 consultations a day 10-15% of all “eye” consultations are for conjunctivitis

  2. Commonest Problems referred to Eye Casualty 1/. Persistent red eye or unresolving conjunctivitis 2/. Corneal FBs/ Corneal abrasions 3/. Flashes and Floaters 4/. Painful eye (Iritis/keratitis) 5/. Reduced vision 6/. Lid problems (styes, chalazions etc) 7/. Contact lens problems 8/. Cellulitis/periorbital swelling 9/. Ophthalmic shingles

  3. Commonest “Mismanagements” 1/. Iritis treated as conjunctivitis 2/. Late referral of Keratitis/Corneal Ulcers 3/. Missed herpetic Ulcers 4/. Missed foreign bodies 5/. “Loss of Vision” (Vision not checked and longstanding) 6/. “Acute Glaucoma” that is not. * GP view might be different! 7/. Episcleritis *Harmless condition *GP view might be different!

  4. Essential Equipment • Visual Acuity Testing Charts. Snellen for adults. (“E” chart with card or Sheridan Gardner for illiterate) Sheridan Gardner for Children >3 yrs Kay picture cards for Children > 2yrs Babies >3/12 following >8/12 100s and 1000s or Preferential looking cards (Orthoptists best) • Pinhole • Ophthalmoscope Blue filter, Green filter for new vessels • Illuminated Magnifying Glass (Auroscope without speculum is good) • Epilating forceps for ingrowing • Fluorets • Proxymetacaine Minims (sting less than Amethocaine) • Tropicamide 1% Minims • Amsler Charts • Ishihara Charts (Red/Green Colour blindness, Optic Neuropathy) • (Red and White Pins (White peripheral VF, Red central VF))

  5. Case Study 1 27 year old builder presents complaining of a FB in his RE His eye is sore and watering and the vision is blurred. He has washed the eye out and it is no better He is seen and a central corneal FB is noted. It is non-metallic and is easily removed with a green needle The cornea appears clear and he is prescribed Chloramphenicol and advised to attend 3 days later to make sure the cornea has healed. Is there anything anyone would do differently?

  6. He returns 10 days later (he was very busy and could not get away earlier) • He says his eye is now very painful and his vision is very blurred • On examination his vision is HM only • He has a complete hypopyon and a small conjunctival puncture wound is noted • He was chiselling when the FB hit his cornea • An USS shows an IOFB. • He is referred to Oxford where he has a total vitrectomy and removal of his FB • 2/12 later his vision has improved to 6/24

  7. Failings • Inadequate history • Vision not checked at presentation • Inadequate examination, conjunctiva not checked, Fundus not checked

  8. History Presenting Complaint • Onset/Triggers (trauma etc) • Vision • Pain/Photophobia • Discharge • Other symptoms (itching/floaters/flashes/diplopia etc.) • Treatment Past Ophthalmic History • Iritis • *Eye Surgery/treatment • Glasses or Contact lenses • *Previous Vision

  9. Past Medical History • Diabetes • Connective tissue disease (RA etc) • Vascular disease • Atopy/Asthma etc Smoking FH • Glaucoma, Retinitis pigmentosa etc Drugs • Steroids • Chloroquine • Amiodarone.

  10. Examination Have a system: Outside to inside of lids. Front to Back of eye. (Requires discipline to stick to) Visionshould always be checked if painful eye or if patient complains of blurred vision (medico-legal protection) If VA reduced always recheck with glasses and pinhole General InspectionProptosis, exophthalmos, Rosacea, etc Lids(Beware small BCCs) Always evert upper lid if FB (use a swab to roll the upper lid) ConjunctivaTarsal and Bulbar

  11. CorneaAlways stainif pain/photophobia or herpes on lids Anterior Chamber Hyphaema if trauma Hypopyon if pain/ulcer PupilReactions Shape (irregular if Iritis) Iris lesions (vessels if CRVO (Rubeosis)) LensCataract Dislocated VitreousOccasional small floater seen on Fundoscopy

  12. Fundus Have a system. • Easier if dilated and in dark room • 15->20degrees temporally, patient looking straight ahead • Follow vessels to disc • Disc Margin, Colour, Pitting, Vessels, Venous Pulse (?) • Macula any abnormality should be taken seriously • Follow out vascular arcades • View periphery. Patient to look into 4 or 8 directions (up/right/down/left/) Eye movements if relevant (eg double vision) Visual fields to confrontation if relevant (red and white pins if keen) Defects: Bitemporal: Chiasmal Homonymous:Behind chiasm All others: In front of chiasm (Nerve or eye)

  13. Case Study 2 Red Eye A 23 year old woman presents with red eyes that are watering and burning. What else would you want to know before making a diagnosis

  14. Some considerations • Contact Lens wearer? • Trauma? • Other family members affected Infective • Onset ? Monocular/ binocular (allergy binocular) • Pain/Photophobia? Suggests Keratitis (beware Herpetic Ulcer) • Vision? If burred Suggests keratitis (bilateral iritis unlikely) • Discharge? Purulent:Bacterial Watery: Viral/allergic • Itching? More likely to be allergic • Treatment ? Allergy to drops • Systemic illness? URTI often accompanies viral conjunctivitis

  15. Conjunctivitis Blepharitis

  16. Episcleritis

  17. Pinguecula Pterygium

  18. Subconjunctival Haemorrhage

  19. Herpes Simplex Conjunctivitis (always stain)

  20. Case Study 3Painful Red Eye A 56 year old man presents with a painful red eye. What else would you want to know?

  21. Painful Red Eye • Onset. Acute? Any trigger? • Past Ophthalmic history: Iritis? Recent surgery? • Past Medical history RA etc • Vision? Blurred in Iritis and keratitis. Very blurred in Acute Glaucoma • Trauma? Detailed history important. ?FB sensation ?Likley to have a hyphaema (E.g. squash ball injury). ?contact lens wear? • Pain. Very severe in Acute Glaucoma often with vomiting • Photophobia? Marked in keratitis and Iritis • Discharge? Muco-purulent suggests possible infective cause, although most painful eyes water a lot

  22. Acute Glaucoma A Medical Emergency needs urgent referral. Optic nerve can be killed within a few hours due to ischaemia if not treated. Principles of treatment are constricting the pupil to unblock the angle and reducing pressure with agents such as diamox

  23. Acute Iritis

  24. Keratitis • A breakdown of corneal epithelium. Caused by trauma, infection, contact lens over wear, dry eyes and exposure • Cornea looks rough, but best seen with Fluorescein staining • Beware Herpes Simplex. Starts as a branching epithelial ulcer that can spread deeper to cause a large geographic ulcer with subsequent scarring and even perforation.

  25. Dendritic Ulcer

  26. If Pain Refer If blurred vision and photophobia Refer

  27. Case 4Eye lid lump A 68 year old presents with a lump on his eye lid What are the likely diagnoses?

  28. Basal Cell Carcinoma of the upper lid

  29. Beware BCC. Easily missed, often picked up as an incidental finding. If large and eroding through tarsal plate can lead to loss of eyeball as impossible to achieve coverage of eyeball after removal

  30. Chalazion

  31. Stye

  32. Herpes Zoster Ophthalmicus Nasocilliary branch involved with vesicles on side of nose meaning that ocular involvement much more likely. (Hutchinson’s Sign)

  33. Case 5Flashes and Floaters A 60 year diabetic gentleman with severe myopia presents with a history of floaters in his Right eye What else would you like to know? What are the likely possible diagnoses?

  34. Useful History Points • Duration • Past Ophthalmic history • Any recent change • Any flashes (Suggest RD or PVD) • Visual loss or blurring (Suggests Vit haem or detachment) Curtain effect suggests Retinal detachment.

  35. Diagnoses • Vitreous haemorrhage (Commoner in diabetics) • Posterior Vitreous detachment (Common, can sometimes cause vit haem, 10% cause retinal tears). • Retinal detachment.Commoner in Myopes( short sighted with thick glasses that make things small)

  36. Case 6Sudden Loss of Vision • A 75 year old gentleman presents complaining of a sudden loss of vision in his left eye What else would you like to know? What are the likely diagnoses?

  37. Useful History Points • Pain suggests Acute glaucoma • Flashes and floaters before suggest Ret Detachment or possible Vitreous haem • Ph of Diabetes suggests haemorrhage likely • Ph of Eye surgery suggests Retinal detachment or macula oedema likely • Ph vascular disease suggests an embolism • Ph hypertension suggests a CRVO as a possibility • Headaches/muscle aches and thick temporal arteries suggest temporal arteritis

  38. Central Retinal Vein Occlusion

  39. Normal Fundus Retinal Detachment (Macula off)

  40. Central Retinal Artery Occlusion

  41. Vitreous Haemorrhage

  42. Temporal Arteritis

  43. Acute Angle Closure Glaucoma

  44. Case 7Blurred vision An 84 year old presents complaining that “her eyes are not so good”. What else would you like to know? What are the likely diagnoses

  45. Useful History Points • Monocular or Binocular • Past ophthalmic history • Previous vision • Recent opticians visit? • Past medical history • Nature of disturbance Glare in bright lights (Cataracts) Central distortion (Macula degeneration)

  46. Dry Macular Degeneration

  47. Case 8 A 66 year old lady presents complaining of persistently watery eyes for a long time. The eyes are not red or itchy but occasionally gritty. The antibiotic prescribed by your partner a month ago have not helped. Her vision is normal. What else do you need to know? What are the likely diagnoses?

  48. Other History Points • When they water. Has she had any recent injury or other treatment? • Any new allergens?

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