1. Jane Goodwin BSc MSc
Nurse Practitioner in Primary Care and Ophthalmic PwSI (practitioner with specialist interest)

2. 3.9.08 – GP Registrar Requests/concerns – what do you want ?
Examination – VA
Case studies
Examination - Ophthalmoscope
Other presenting problems
Questions

3. Examination Visual Acuity To asses distant vision.
To determine if a refractive or pathological disorder.
Baseline
Medico/legal requirement.
Minimum for driving 6/12.
Very few people are completely blind.
Blind registration 3/60 in both eyes or 6/60 in both with restricted visual field.
Partially sighted – 6/60 or worse in both eyes or 6/18 in both eyes with restricted visual field.
Clear print guidelines – black on yellow

4. Equipment Pen Torch Pin Hole Snellen Chart Ophthalmoscope Fluorescien
Benoxinate
Tropicamide
This is sort of equipment you’ll need to have about the surgery.

5. Your Turn! In groups of 3 or 4 3 metres from chart
Measure Va in each eye
See instructions for further reference

6. Case Studies - One The opticians letter states
‘this man has a cataract in the left eye and I have advised him to seek a specialist opinion’
His VA is 6/9 right and 6/12 left
What do you do as a GP?
Are there any options?
It is reasonable to assume that the patient has a cataract and that a routine referral is required.
Other considerations :-
Does the patient feel the need for the surgery
Consider lifestyle issues ie ability to drive, to do job or care for a relative – these also deserve a mention in your referral letter.
NB Extreme old age or poor health are not bars to surgery.

7. Two
Ten weeks after uncomplicated cataract surgery a patients requests a further prescription of G. Maxidex. He missed his post operative review.
What are you going to do ?
Maxidex is a corticosteroid drop commonly used after surgery to control post operative inflammation.

8. Commonly used post op for 3-4 weeks QDS.
Is normally stopped at post op visit.
Request should be denied esp if eye white/asymptomatic.
Early review at OPA

9. Three
One year after cataract surgery, a patient complains of gradual deterioration in vision, in the operated eye.
What is the likely cause?
What do you do ?
20-30% pt’s will develop posterior capsule opacification (caused by residual lens fibres)
An other possibility for this age group for a deterioration in Va is ARMD
HOW may you tell the difference ? Abnormal red reflex due to Capsule thickening.
Referral for YAG laser.

10. Four
A 50 year old man notices a single black object in the field of his left eye. It moves on eye movements.
What is likely cause?
What will you do?
What features would concern you?
Most likely cause is a PVD – floaters are common and can be single or multiple and described a a cobweb or fly that they can’t wipe away from field of vision.
Next Slide – flow chart

11. Flashes and Floaters Decreased Va? Yes NO Continued Transient
Typically 20 minutes
Duration
-Vitreous Haemorrhage Ocular Migraine -PVD
-PVD with retinal detachment (+/- retinal hole formation)
-Posterior Uveitis
Worrying features are if the vision is decreased
And you would refer using the following criteria – NEXT slide.

12. Referral Guidelines Flashing lights and floaters
Retinal holes and detachments – difficult to see with ophthalmoscope.
Hx >6/52 Routine Referral
Hx < 6/52 esp in under 55’s urgent OPD referral
Hx recent onset with decreased VA – URGENT A/E

13. Five
A 28 years old female presents with a smooth, round swelling in Left upper lid. It has been present for 2 months.
What is the likely diagnosis?
What do you do?
MOST LIKELY DIAGNOSIS - Meibomian cyst.

14. Stye (abscess formation at root of lash)
Meibomium cyst (Chalazion)
Stye
Root of eye lash infected
Pain tender lid swelling
Steaming, epilation of lash
ABx drops
Meibomian
Blockage of Meibomian glands
glands along tarsal plate.
Tender, swollen upper or lower eye lid.
Rx Abx and steaming
Most resolve within 3 -4 months, but refer to local ophthalmic minor ops for removal when persistent.
What other eye lid infections would be of concern ?
Go to next slide

15. Orbital cellulitis Preseptal cellulitis Preseptal
Infection of tissues in front of orbit
Symptoms
Frontal headache, inability to open eyelid, systemic fever.
Signs
Facial cellulitis with gross swelling of eyelid, closure of lid
Would expect full range of movement and normally good Va.
Causes
Sinusitis in young children, cellulitis of lids from infected Meibomian cyst.
Management
Immediate referral to A/E and treated with oral/IV Abx.
Orbital
Lid swelling, eye proptosed, chemosis, limited ocular movements, difficulty opening eye. Abnormal pupil reaction. Optic disc swelling, sinus tenderness.
FEVER, headaches diplopia and loss of va
Orbit is usually infected by neighbouring structures – often sinus.
LIFE THREATENING – urgent referral. Admission IV abx.
Orbital cellulitis
Preseptal cellulitis

16. Six
A 20 year old women presents with bilateral red eyes that are gritty and burning. Discharge is evident on the lashes.
What is the likely diagnosis ?
What else could it be?
Bacterial Conjunctivitis is the most likely cause.
Treatment with G.chlor QDs or Fucithalmic BD for 1/52 normally does the trick!
The presence of pus excludes most other things, and examination of the cornea with Fluorescien excludes other things like a corneal ulcer.
It is important to note if the pt wears CL and after excluding ulceration to leave them out for 10/7, ensure thorough cleaning or a new pair if disposables.
Other possibilities can be viral with secondary bacterial infection and Chlamydia if sexually active.
Whilst on the topic of conjunctivitis next slide shows an allergy.

17. Vernal Conjunctivitis
Chemosis - Conjunctival swelling from allergy and excessive rubbing
Vernal
On eversion of upper eye lid . Tarsal Plate covered in large follicles – like a cobble stone street.
Common in atopic persons – hay-fever and allergy to pets etc.
Intensely Itchy, watery eyes which if excessive rubbing can cause Chemosis
NEXT slide
Rx antihistamine drops / oral
Octrivine antistin quick acting, opticrom takes 24hr before useful, but effective if used regularly.
AND BLEPHARITIS – NEXT SLIDE

18. Oil secretion from Meibomian Glands
Over secretion of oil from Meibomian glands causing blepharitis
Burning, itching, FB sensation, crusting around eyelashes.
Frequently associated with dry eye and eczema.
Chronic Staph infection and is best treated with lid hygiene and ABx drops
WHICH REQUIRES LID HYGIENE – NEXT SLIDE
Blepharitis

19. Lid Hygiene 150ml Cooled boiled water 1 tea spoon Baby shampoo
Mix and store in fridge up to 1/52
Using cotton bud – clean top and bottom lashes (as if putting on eye liner)
Daily for 2/52 then decrease to twice a week indefinitely

20. Seven
A 24 year old man presents with a painful left red eye that has been present for 5 days and has been getting worse every day. He is quite photophobic.
What do you do ?
What conditions do you consider ?
IN THE ABSENCE OF PUS AND THE INCREASE IN PAIN AND PHOTOPHOBIS ARE WORRYING SIGNS.
Check Va to see if also affected.
Lets have a list of all the possible diagnosis
Acute glaucoma
Dentritic or bacterial ulcer
Iritis
Scleritis

21. Episcleritis Scleritis Episcleritis
Localised redness on either inner or out canthus, with discomfort on movement.
Deep blood vessels engorged, may have nodule appearance.
Pain can be variable, dull ache.
Most resolve spontaneously with No Rx
If persistent and severe referral for steroid drops.
Scleritis
V engorged deep scleral vessels. Can be confirmed as these vessels can not be moved with a cotton bud.
Severe deep pain, headaches, photophobia
Not too common but associated with autoimmune systemic diseases, post herpes.
Immediate referral to Eye cas for possible IV steroids
THIS LEAVES DENTRITIC ULCER OR IRITIS – GO TO NEXT SLIDE
Scleritis

22. Typically present with a red, photophobic eye, decrease in Va and tearing.
Flourescien staining show branch of tree.
Reduced corneal sensation in that eye
Tissue test.
Herpes simplex Virus can be 1 or 2.
Rx Acyclovir 5 x daily and CT until no dentrites seen.
Dendritic Ulcer

23. Anterior Uveitis (Iritis)
Particular bad case
Unreactive, irregular pupil as stuck down to lens (Posterior synechiae)
Photophobic, red cliary injection and very painful.
Blurred Va
Slit lamp Ex, inflammatory cells in AC and KP on endothelium
Requires intensive Rx corticosteroid drops and then CT for 4 -6 weeks – Must not be started unless Dentritic ulcer excluded.
Can be associated with systemic disease such as ankylosing spondylitis and sarcoidosis.
THEREFORE THIS HX AND SX SHOULD BE REFERRED URGENTLY TO EYE CASUALTY.
Anterior Uveitis (Iritis)

24. Eight
An 80 year old women complains of a very painful eye along with a feeling of nausea of 2 days duration. On examination the eye is red.
What condition do you want to exclude ?
How do you do this ?
Acute glaucoma.
Examine the pupil – in acute glaucoma is mid dilated fixed, un-reactive to light and digital palpitation with be hard.
As IN THESES NEXT SLIDES

25. Acute Angle Closure Glaucoma
Acute red painful, throbbing eye. Haloes around lights, headache and nausea and vomiting
NB Pt’s have been admitted for GI investigations for vomiting in past.
Hazy cornea, intense injection around cornea. Mid fixed dilated pupil
STONY HARD ON PALPATION – SEE NEXT SLIDE.
Caused pt’s with shallow AC ( Hypermetropes) Bigger eye ball.
Drug induced – dilating drops in at risk eyes.
Previous injury
Pt’s with Hx of drainage angle abnormalities.
URGENT REFERRAL
Digital Tonometry

26. Coffee Time !

27. Nine
A 75 year man complains of sudden loss of vision in one eye. Visual acuity is ‘hand movements’ only.
What are the likely causes?
What condition do you especially want to exclude ?
How do you do this ?
Given the patient age vascular causes are at the top of the list
These would include
Central ret vien occ
Central ret art occ
Ischemic neuropathy – Temporal arteritis
Macular haemorrhage
Vit haem
2. Other condition to exclude is Giant cell arteritis
3. Direct questioning – polymyalgia rheumatica, malaise wt loss, scalp tenderness pain on chewing or talking.
Your examination would comprise of Va, Visual field, Red Reflex Pupil reactions and fundus.

28. Central Retinal Artery Occlusion
Milky white Retina with Cherry Red spot at the macula.
Can present with sudden loss of vision or have transient vision loss a few days before.
Unilateral acute painless loss of Va.
Whitening of the Retina – looks pale and allows glow at the macula from unaffected choroidal circulation – this is called a Cherry red spot
Afferent pupillary defect
Visual acutity perception of light
Causes
Emboli from major arteries in head and from Left side of heart.
Clots, Ca deposits, Inflammation from Giant cell arteritis
Risk factors
Over age of 50
Hypertension.
Raised cholesterol
Diabetes
Carotid artery disease
Management
Urgent referal to A/E, Immediate occular massage and lowering of intraocular pressure may improve outcome.

29. Central Retinal Vein Occlusion
Central vein which drains blood from the retina becomes blocked, causing a back flow of blood, hence the vessels leaking into the retina causing swelling.
Ischemic causes of a blockage increases complications. Abnormal growth of blood vessels occur.
Some can be treated with Laser

30. Optic Neuritis/Papilloedema
Think Young Females
Decreased visual acuity RAPD
Pain on ocular movement.
Papilleodema
Va and RAPD normal
Causes
Raised Intra cran pressure,
Brain tumour
hypertension.
meningitis

31. Examination of Fundus Requires practice and confidence.
More accurate with dilated pupil.
Knowledge of A&P to interpret findings.
Limited view with direct ophthalmoscope.
See separate hand out on how to do

32. RAPD (relative, afferent, pupillary, defect)
RAPD is testing the nerve pathways to the brain. Inflammation, damage, or pressure on the nerves will cause a defect.
Light shone into a healthy eye causes constriction in both eyes. Swing light to other healthy eye and same reaction will occur. Repeat 3 or 4 times.
In a damaged eye – on swinging light to damaged eye neither pupil will constrict and damaged eye will start to dilate.
Next slide with diagram

34. Ophthalmoscope Practice
Find tops tips for using ophthalmoscope in hand out
Get into small groups
Practice !!!!!

35. Ten
A 60 year lady complains of recent onset of distorted and blurred vision especially when reading the newspaper.
What eye conditions do you suspect?

36. Age related Macular degeneration
Cataracts
Diabetic Retinopathy
Hypertension

37. ARMD – wet & dry
Dry – 80% (however, 1 in 10 patients will develop wet)
Cells under the macular break down & cause drusen (yellow deposits) under the retina.
Signs – print is blurred, colours are dull, vision can be hazy and central vision is affected

39. WET Abnormal growth of blood vessels that leak blood and fluid.
Causes scarring& permanent loss of central vision
Signs – lines becomes wavy, door frames appear wonky.
Onset is usually rapid.
Early diagnosis is critical if sight is to be saved

41. Risk Factors Increases with age Fhx / genetics
Gender – more common in females
Smoking
Obesity
Poor nutrition – enc colourful veg
CVD
Caucasian

42. Treatment
Lucentis and Macugen – blocks abnormal vessel growth and leakage and targets proteins that are thought to cause ARMD.
Intravitreal injections every 6 weeks 9 times a year.
Post Rx – redness, specks in vision, Abx are commonly prescribed & monitor with amsler chart

43. Brief look at other conditions

44. Diabetic Retinopathy Known as Background or Non-proliferative
Hard exudates – yellow flecks deep in the retina reflecting leakage of incompetent pre capillary retinal arterioles
Haemorrhages – ‘red dots’ show mini blow outs of the diseased pre capillary arterioles

45. Proliferative
This shows the tangling of blood vessels at the optic disc & nearby retina.
The vessels are weak walled & break easily. They bleed into the retina & vitreous jelly & can cause retinal detachment & blindness.
Treatment with argon laser is helpful

46. Glaucoma
As a rule optic disc assessment is difficult as there is an infinite variety of normal optic discs.
The main visible sign is thinning of the neuroretinal rim causing a larger central cup. As the disease progresses the rim is eroded until there is little or no rim left.
Cupped disc
Normal disc

47. Disc Oedema with Hypertension
Disc oedema with splinter haemorrhages
Caused from severe hypertension

48. Guess the condition

49. (removed for cosmetic purposes)
Basal cell Carcinoma
Papilloma
(removed for cosmetic purposes)
BBC
Accounts for 90% of eyelid tumours.
Most common in elderly and fair skin high levels of sun in younger individuals.
Slow growing, rodent ulcer
Loss of eye lashes, ulceration, dilated blood vessels, pearly lesion.
Papilloma – removed for cosmetic purposes

50. Cyst of Moll Cyst of Zeis Cyst of moll
Common lesions on the lid margin.
Small round translucent appearance, usual fluid filled, easily poped with a needle.
Cyst o Zeis
Similar to cyst of moll but is not translucent – is filled with oily secretions.
Can be popped with a needle but tends to refill.
Cyst of Zeis

51. Pinguecula Pterygium Pterygium Triangular growth over conj
Most common in those who live in hot sunny climates or work outdoors.
No treatment except in bad cases where cosmetically needs removal and encroaching over cornea
Pinguecula
Similar to pterygium but does not encroach the cornea.

52. Watery eyes – epiphora
LSWO
Babies refer after 15 months

53. Entropian Ectropian Entropian Lid turning in
Comes with old age and secondary to chemical burns.
Red sore eye, FB sensation.
Rx – temporary taping of eye lid, lubricant and referral.
Ectropian
Excess tearing, sore and irritable eye
Corneal damage from drying out
As a result of aging
Rx – lubricants and referral for corrective surgery
Ectropian

54. Xanthelasma Milia Xanthelasma Fatty deposits around the eyes
Indication of hypercholesterolaemia
No Rx
Milia
Crops of tiny white cysts
No treatment
Milia

55. Rust Ring Corneal Foreign Body Corneal FB
May be obvious like this or revealed by using fluorescien.
FB sensation, Hx of grit blowing into eye or hammering/grinding.
Need to Exclude Perforation
Requires removal – dependent on experience and skill.
Benoxinate,
Performed on slit lamp
Rust Ring
Rust rings remain and need removal – soften with occ chlor 24 – 48 hrs and remove in same way.
WARNING not to be over zealous with debridement or may lead to permanent scaring.
Rust Ring

56. Conjunctival Melanoma
Pigmented Lesion
Conjunctival Melanoma
Pigmented Lesion
Conjunctival nevus
Benign and unilateral
Can be melanoma but very rare under age of 50
Reassure and in some bad cases removal can be considered.
Melanoma
Tumour on conjunctiva – pigmented nodule fixed to the sclera
Rare – seen in pt’s over 60

57. Paediatric ophthalmology
Development of eyes reaches full maturity at 7 years of age.
At birth an inborn reflex normally brings the image of an object onto the foveae of both eyes. Over time continual practice of this reflex is cemented into the ability to perceive depth.
This can break down in two situations……

58. What are they? If one eye has poor vision - eg Congenital Cataract
High refractive error
Ptosis – drooping eye lid
Other pathology such as retinoblastoma
2. The other if one eye is squinting

59. Squint
Brain ignores the image from poor eye and concentrates on the good eye.
The poor eye turns in (convergent squint) and to avoid double vision the brain suppresses the image from this eye.
If not corrected early, the eye does not develop hence the vision remains poor for life.
This is the same for the amblyopic eye

60. Final Question
Mother with 3 year old child presents saying she has noticed the Childs eye turning inwards.
O/E - you did not find any evidence of a squint
What do you do?

62. What you need to know! Diagnostic drops to have in your surgery
Benoxinate – anaesthetic – last for 20 mins great for FB removal.
Fluorescein – orange dye for ocular surface problems
Tropicamide – if need a clearer of view of fundus
Glaucoma drops – check for bradycardia, and SOB. Most can be prescribed in packs of 3 – this is cheaper to prescribe and convenient for pt.
Prostaglandin drops used in glaucoma eg Latanoprost cause eye lash growth, change in iris pigment and discolouration of skin under lower lid.
Corticosteroid drops – never prescribe unless undergoing regular monitoring at local eye unit
Artificial Tear drops / ointment – there are loads – start with hypromellose, then progress to gel tears and lacri-lube at night
Antiviral ointment – I doubt you’ll prescribe without confirmation of herpetic infection
Antibiotic ointment / drops – next slide

63. Chloramphenicol Ointment 1% - QDS Drops 0.5% - QDS Abraisions
Dry eye syndrome
Soften FB or rust ring
Easier to apply if tube warmed in hand/pocket.
Size of grain of rice
Drops 0.5% - QDS
Bacterial infection
No blurring of Va
To be stored in fridge
DO not use in SOFT contact lens use.
Asses if can instil drops

64. Fucithalmic Gel / drops 1%
BD use as long acting 12hrs (no benefit using more frequently).
Can sting for 10 secs on instillation.
More convenient to use.

65. Chloramphenicol v Fusidic
Mini Review
Reference
Griffiths P (2003) What type of eye drops should be given to a toddler with conjunctivitis? British Journal of Community Nursing, Vol 8 No 8 pg 364

66. Local Services to Epsom
Surrey Association for Visual Impairment (SAVI)
Tel
Epsom and Ewell Club for the blind
Tel
Swail House – Ashley Rd - Housing for visually impaired -

67. Questions
The End

68. References BNF 46 (2003) September
Galbraith A et al (1999) Fundamentals of pharmacology, A text for nurses and health professionals. Addison Wesley Longman Ltd.
Gregory R (1998) Eye and Brain, The Psychology of Seeing, 5th Ed Oxford University Press, Oxford.
Griffiths P (2003) What type of eye drops should be given to a toddler with conjunctivitis? British Journal of Community Nursing, Vol 8 No 8 pg 364.
Kanski J (1999) Clinical Ophthalmology, Butterworth-Heinemann, Oxford.
Maclean H (2002) The Eye in Primary Care , Butterworth-Heinemann, Oxford.
Pavan-Langston D (1996) Manual of Ocular Diagnosis and Therapy, 4th Ed, Little Brown and Company, Boston.
Stein H (1992) Ophthalmic Terminology, 3rd Ed Mosy Year book, London.
Stollery R (1997) Ophthalmic Nursing, 2nd Ed, Blackwell Science.