Presentation on theme: "Idiot’s guide to eye problems"— Presentation transcript:
1 Idiot’s guide to eye problems Cass AdamsonJanuary 2011
2 What do GPs need to know? Many conditions Wealth of info GP books short chaptersSerious consequences if wrongThere 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 problemsVideos on eye examinations (optional)Practical session for practising fundoscopy and other eye examinationsCSA practiseTried 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 fieldsPupils + swinging torch testFundoscopyEye movementsWith these simple assessments most decisions can be made regarding possible cause and management
6 “There’s something in my eye” Joan Peters 65Controlled hypertension5/7 ago sudden appearance of ‘tadpole’ in L eye with some flashing lights.No traumaVision NADSymptoms 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 – 6/5L – 6/6Fundoscopy: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 wormRefer routinelyRefer urgentlyRefer 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 urgentlyMost 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 fromperipheryBlurred central visionOften 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 floatersFloaters large and red or blackTearing or bleedingFloating blobs or severe visual lossFloaters 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 47Occasional headachesLast night sudden onset diplopia and a headache which is worsening.Taken some ibuprofen, partial reliefConsulted 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 mediallyPartial ptosisL 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 worsenPrescribe analgesia for headacheAsk optician to examine fundi then r/v patientRefer routinelyRefer urgentlyRefer immediately
15 New sudden onset diplopia adult has a life threatening cause eg aneurysm until proven otherwise → immediate referralGradual 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-BarreMyasthenia gravisEarly cataractCN III, IV, VI palsiesOther signs to look for:Enlarged pupil, ↓ response light – CN III palsyPtosis – CN III palsy or MGLid retraction – thyroid eye diseaseRed eye – thyroid eye disease or orbital inflammationOcular torticollis – CN IV palsyCheck 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 upCN 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 eyeVisual field defectRAPDAbnormal cornea, iris or pupilLoss red reflexOptic disc swelling or pallorSerious eye/brain disease likely if symptoms:Unexplained eye painPhotophobiaDistortion visionFlashes of lightNew floatersLoss part visual fieldSx temporal arteritis
18 “ I can’t see in my left eye!” Hannah Cook 76Type 2 diabetes and hypertensionThis morning sudden reduced vision L eyeMildly painfulDH: bendroflumethiazide, metformin, simvastatin and aspirin
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 DMMake sure she sees her optician soon as her glasses are clearly inadequateRefer routinelyRefer urgentlyRefer immediatelyNo 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 veinsMacular oedemaOptic disc swelling+/- cotton wool spots.Proliferative Diabetic Retinopathy:Cotton wool spotsHard exudatesDot and flame haemorrhagesOptic 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 defectCentral retinal artery occlusion:Sudden painless loss all vision↓↓↓ VA (light only), RAPDPale retina, cherry red maculaBut distribution shows branchPt 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
29 What do you do? Refer for routine CT/MRI head Refer for urgent CT/MRI headCall 999Admit medical teamRefer to ophthalmology routinelyRefer to ophthalmology urgentlyNeeds 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 hypertensionAny 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, worseningOtherwise asymptomaticL 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 SyndromeOther causes:Head or neck traumaBrainstem strokeDissecting internal carotid aneurysmPancoast’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 syndromeDouble vision or limited eye movements: MG or CN III palsyPupil small: Horner’sPupil large: CN III palsyFatigability: MG→referUnilateral = any causeModerate or severe = any causeRefer 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 PMHTakes COCP
35 Unilateral dilated pupil Poor or no response light. Adie’s pupilUnilateral dilated pupilPoor 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.
37 More words of wisdom:Not all flashing lights with headache are migraineBlurred vision or headache needs field testField loss always needs assessmentSudden onset visual distortion – urgent refConsider temporal arteritis every pt >50 with headache or visual changeThe TAKE HOME MESSAGESOccipital 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 disprovedNew onset flashes and floaters are retinal detachment until proven otherwiseChildhood 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 Ophthalmology3. Practical Ophthalmology – A Survival Guide for Doctors and Optometrists (2005). A. Pane and P. Simcock4. Symptom Sorter 4th ed (2010). K. Hopcroft and V. Forte5. The 10-Minute Clinical Assessment (2010). K. Schroeder6. Google images!