1. Eyes in General Practice
Dr Bruce Davies

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. An easy list really as they all need specialist assessment!
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.

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?