1. Idiot’s guide to eye problems
Cass Adamson
January 2011

2. What do GPs need to know? Many conditions Wealth of info
GP books short chapters
Serious consequences if wrong
There are hundreds of eye conditions, and considerably more information about them all available.
What do we actually need to know?
Most GP text books have surprisingly short chapters on ophthalmology. Suggests we don’t need to know specifics or details about most conditions. Patients present with symptoms – we need to be able to quickly and simply identify whether serious problem or not through just history and a basic eye examination.
Actually need to know investigations and management of a handful of problems, the rest will be seen by optician, ophthalmologist or other professional (eg neuro) and we can continue management.

3. Take home message:
If in doubt – REFER!!!
Golden nugget

4. Session plan:
Presentation on assessing and managing common or serious eye problems
Videos on eye examinations (optional)
Practical session for practising fundoscopy and other eye examinations
CSA practise
Tried to adopt very simplistic approach – does anything need doing? If so, what?
Not covering red or itchy eyes/eyelid probs as most e-learning modules and GP targeted info seems to cover these

5. Eye assessment External examination of eyes and face Visual acuity
Visual fields
Pupils + swinging torch test
Fundoscopy
Eye movements
With these simple assessments most decisions can be made regarding possible cause and management

6. “There’s something in my eye”
Joan Peters 65
Controlled hypertension
5/7 ago sudden appearance of ‘tadpole’ in L eye with some flashing lights.
No trauma
Vision NAD
Symptoms started whilst watching TV. Also noticed a brief black shadow edge of lateral vision L eye.
Flashes resolved but ‘tadpole’ still there. Thought it would ‘go away’.
Wears glasses but no change Vision – last check 1 year ago, not had glasses changed for years

7. BP 148/79 Eyes appear normal PEARL Eye movements NAD Fields NAD
VA (with glasses)
R – 6/5
L – 6/6
Fundoscopy:
Feels well in herself. No recent illness.
Fundoscopy – retina nad, but floater seen ‘swimming’

8. What do you do? Reassure her Advise optician r/v
Ask about foreign travel and explain that the ‘tadpole’ could be a worm
Refer routinely
Refer urgently
Refer immediately

9. Posterior vitreous detachment - normal examination
- Floater black ‘cobweb’ or ‘curtain’
But new flashes and floaters are retinal detachment or retinal tears until proven otherwise.
→ refer urgently
Most common cause – PVD which is common later middle ages and benign – vitreous jelly breaks into solid and liquid parts and the solid part peels off retina.
Cannot exclude retinal detachment with ophthalmoscope hence need referral for thorough examination and assessment.
Typically vision and fields normal, pupils normal, no RAPD.

10. Retinal detachment Rhegmatogenous or traction. Flashes, floaters and
field loss – curtain from
periphery
Blurred central vision
Often notice a shadow or ‘curtain’ peripheral vision as well as flashes and floaters.
Increased risk if myopic (short sighted).
Rhegmatogenous – tear in retina, fluid behind strips retina forward. Usually progresses peripheral tear towards macula. Takes hours-days usually.
Traction – abnormal blood vessels in proliferative diabetic retinopathy pull retina off.
If macula unaffected visual acuity may be normal, but might see RAPD or field defect

11. Retinal tear Vitreous haemorrhage
Flashes and floaters
Floaters large and red or black
Tearing or bleeding
Floating blobs or severe visual loss
Floaters might be large and red or black if tear has caused vitreous haemorrhage.
Vitreous haemorrhage caused y normal vessels tearing eg retinal tear or abnormal vessels bleeding eg prolif diabetic retinopathy. Or trauma.
If haemorrhage only and no retinal detachment, will not see RAPD. Visual acuity normal or reduced. Decreased or absent red reflex if severe.
Haemorrhage more common with diabetes.

12. “It’s double vision, Doc”
Hanif Khan 47
Occasional headaches
Last night sudden onset diplopia and a headache which is worsening.
Taken some ibuprofen, partial relief
Consulted with headaches few times previously. No other PMH.
No vomiting. Doesn’t feel quite right.

13. L eye looking down and outwards
Unable to look up, down or medially
Partial ptosis
L pupil slightly dilated and less reactive to light

14. What do you do?
Inform him it is a CN III palsy and to come back if his symptoms worsen
Prescribe analgesia for headache
Ask optician to examine fundi then r/v patient
Refer routinely
Refer urgently
Refer immediately

15. New sudden onset diplopia adult has a life threatening cause eg aneurysm until proven otherwise → immediate referral
Gradual onset diplopia in adult can be tumour.
Can see transient or persisting diplopia with temporal arteritis

16. Causes of diplopia: Intoxication Head injury CVA Orbital floor #
Guillain-Barre
Myasthenia gravis
Early cataract
CN III, IV, VI palsies
Other signs to look for:
Enlarged pupil, ↓ response light – CN III palsy
Ptosis – CN III palsy or MG
Lid retraction – thyroid eye disease
Red eye – thyroid eye disease or orbital inflammation
Ocular torticollis – CN IV palsy
Check they mean diplopia and not blurred vision.
Thankfully not common in GP, but A&E admit many people for overnight observation as cannot exclude serious cause until sober.
Orbital floor # - difficulty looking up
CN III and VI most common. VIth palsy – horiontal diplopia and unable to look laterally affected side. IVth palsy – vertical or oblique diplopia. Can be very difficult to detect clinically – often need to use cover test. Pt may have a head tilt to the opposite side.

17. Blurred vision: Serious eye/brain disease likely if signs:
Red eye
Visual field defect
RAPD
Abnormal cornea, iris or pupil
Loss red reflex
Optic disc swelling or pallor
Serious eye/brain disease likely if symptoms:
Unexplained eye pain
Photophobia
Distortion vision
Flashes of light
New floaters
Loss part visual field
Sx temporal arteritis

18. “ I can’t see in my left eye!”
Hannah Cook 76
Type 2 diabetes and hypertension
This morning sudden reduced vision L eye
Mildly painful
DH: bendroflumethiazide, metformin, simvastatin and aspirin

19. BP 156/66
Last HbA1c 7.9%
VA (with glasses)
R – 6/9
L – 6/18
Eye movements NAD
Possible RAPD
Fundoscopy:

20. What is it?
Linked with hypertension, diabetes and chronic glaucoma. Consider hypercoaguable state eg myeloma.

21. What do you do?
Review her medications and add in a further agent for BP and DM
Make sure she sees her optician soon as her glasses are clearly inadequate
Refer routinely
Refer urgently
Refer immediately
No treatment for it though. Important to reduce CV and coagulation risks. Ophthalmology will observe and if new vessels, laser photocoagulation therapy.

22. Central retinal vein occlusion: Widespread retinal haemorrhage
Tortuous dilated veins
Macular oedema
Optic disc swelling
+/- cotton wool spots.
Proliferative Diabetic Retinopathy:
Cotton wool spots
Hard exudates
Dot and flame haemorrhages
Optic disc swelling in one eye suggests disease within eye, not raised ICP

23. Branch retinal vein occlusion: Appearance similar to CRVO
Sx: sudden blurring or field defect
Central retinal artery occlusion:
Sudden painless loss all vision
↓↓↓ VA (light only), RAPD
Pale retina, cherry red macula
But distribution shows branch
Pt has sudden blurring of vision and/or partial visual field defect.
CRAO – loss vision ONE eye.
Usually caused by atherosclerotic clot, also linked temporal arteritis, hypertension, and DM.
Needs immediate referral (for reduction IOP within hours to prevent further visual loss).
Branch retinal artery occlusion – sudden painless loss section of visual field and/or blurring central vision. Usually secondary to stenosed carotid artery. See sectoral retinal pallor, reduced VA and/or visual field defects

24. Transient visual loss:
ONE
BOTH

25. Sudden or rapid visual loss:
ONE
BOTH
If the eye is red, separate assessment
ARMD = age related macular degeneration
Bilat acute optic neuropathy – eg temp arteritis
YES NO

26. Gradual visual loss: NO
YES
If the eye is red, separate assessment

27. “My eyes keep going funny”
Jemima Duck 26
Had headache past 3/52. 4/7 when bending forwards nausea and transient visual loss
BMI 29.6
Takes COCP
No PMH

28. ?RAPD (subtle)
Eye movements NAD VA
L - 6/9
R – 6/12
Fields - ?central scotoma
Fundoscopy (bilateral):

29. What do you do? Refer for routine CT/MRI head
Refer for urgent CT/MRI head
Call 999
Admit medical team
Refer to ophthalmology routinely
Refer to ophthalmology urgently
Needs urgent imaging to exclude intracranial pathology. If clinically well and able to arrange scan soon, could arrange urgent imaging then refer to appropriate team.
She has urgent CT scan – NAD.
What is the diagnosis?
BIH is raised ICP in absence intracranial in absence mass lesion or hydrocephalous – more common younger females, COCP, obesity, smokers. In women it may coincide with recent weight gain, fluid retention, the first trimester of pregnancy and the postpartum period.
Often idiopathic. Due to reduced absorption CSF by arachnoid villi.

30. Papilloedema: Unilateral – disease within eye Bilateral - ↑ICP
Raised ICP – brain tumour, traumatic brain oedema, intracranial haemorrhage.
Also severe acute hypertension
Any cause of acute or chronic optic neuropathy – eg anterior ischaemic optic neuropathy sec to atherosclerosis or temp arteritis, MS, infectious optic neuritis, infiltration optic nerve by sarcoid or tumour, B12 deficiency.
Photos – L to R – mild to severe papilloedema then chronic changes. Initially disc ‘disappears’ then swelling seen and finally appears distorted.

31. “My eye is droopy” Bob Smith 54 year old smoker.
5/7 drooping L eyelid, worsening
Otherwise asymptomatic
L eyelid partial ptosis, L pupil smaller. Light response: constricts briskly light, poor dilation dark

32. Possibly some weight loss Longstanding mild dry cough
Probable Pancoast’s Syndrome
Other causes:
Head or neck trauma
Brainstem stroke
Dissecting internal carotid aneurysm
Pancoast’s syndrome = Horner’s syndrome secondary to pancoast’s tumour (Apical lung tumour)
Ptosis – age related (aponeurotic) due to stretching and thinning of levator muscles most common – usually see bilat ptosis but one eye is worse. Other cause of bilat is MG. Unilat more likely to be CN III palsy or Horner’s.

33. Approach to ptosis: Bilateral: age related or MG
Mild: Horner’s syndrome
Double vision or limited eye movements: MG or CN III palsy
Pupil small: Horner’s
Pupil large: CN III palsy
Fatigability: MG
→refer
Unilateral = any cause
Moderate or severe = any cause
Refer to exclude serious underlying cause.

34. “My eye looks odd” Sarah Brown 19yr.
Her mother noticed her R eye looked ‘odd’ this morning.
Recent bad cold.
No PMH
Takes COCP

35. Unilateral dilated pupil Poor or no response light.
Adie’s pupil
Unilateral dilated pupil
Poor or no response light.
Usually unilateral dilated pupil due to paralysed iris sphincter secondary to lack of parasympathetic supply.
Unknown cause but possibly follows viral infection.
Resolves spontaneously with time.

36. Unequal pupils:
YES NO
YES
YES NO NO

37. More words of wisdom:
Not all flashing lights with headache are migraine
Blurred vision or headache needs field test
Field loss always needs assessment
Sudden onset visual distortion – urgent ref
Consider temporal arteritis every pt >50 with headache or visual change
The TAKE HOME MESSAGES
Occipital tumours and vertebrobasilar TIA can present with flashes too.
Field testing may be only way to detect tumour eg pituitary.
Urgent assessment if field loss sudden or visual pathway disease suspected.
Sudden visual changes likely to be acute macular disease – needs urgent referral.
Consider temp arteritis >50 with transient or persisting vision loss or double vision. New headache, scalp tenderness, jaw ache on chewing, ear or neck pain, weight loss, fatigue, muscle aches. Temporal arteries that are tender to palpate and/or not pulsatile. Urgent ref is suspect.

38. Red eye with decreased vision, pain or photophobia needs same day referral.
Any child with a turned eye has sight/life threatening condition unless disproved
New onset flashes and floaters are retinal detachment until proven otherwise
Childhood tumours of the brain and eye often present with a turned eye. Plus, they rarely ‘grow out’ of strabismus – delayed treatment can cause permanent visual loss.

39. References: 1. Pulse Plus – Ophthalmology
2. Pulse – Picture quiz: Acute Referrals to Ophthalmology
3. Practical Ophthalmology – A Survival Guide for Doctors and Optometrists (2005). A. Pane and P. Simcock
4. Symptom Sorter 4th ed (2010). K. Hopcroft and V. Forte
5. The 10-Minute Clinical Assessment (2010). K. Schroeder
6. Google images!

40. Funsdoscopy: