Presentation on theme: "Jane Goodwin BSc MSc Nurse Practitioner in Primary Care and Ophthalmic PwSI (practitioner with specialist interest)"— Presentation transcript:
1Jane Goodwin BSc MScNurse Practitioner in Primary Care and Ophthalmic PwSI (practitioner with specialist interest)
23.9.08 – GP Registrar Requests/concerns – what do you want ? Examination – VACase studiesExamination - OphthalmoscopeOther presenting problemsQuestions
3Examination Visual Acuity To asses distant vision. To determine if a refractive or pathological disorder.BaselineMedico/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
4Equipment Pen Torch Pin Hole Snellen Chart Ophthalmoscope Fluorescien BenoxinateTropicamideThis is sort of equipment you’ll need to have about the surgery.
5Your Turn! In groups of 3 or 4 3 metres from chart Measure Va in each eyeSee instructions for further reference
6Case 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 leftWhat 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 surgeryConsider 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.
7TwoTen 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.
8Commonly 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
9ThreeOne 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 ARMDHOW may you tell the difference ? Abnormal red reflex due to Capsule thickening.Referral for YAG laser.
10FourA 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
11Flashes and Floaters Decreased Va? Yes NO Continued Transient Typically 20 minutesDuration-Vitreous Haemorrhage Ocular Migraine -PVD-PVD with retinal detachment (+/- retinal hole formation)-Posterior UveitisWorrying features are if the vision is decreasedAnd you would refer using the following criteria – NEXT slide.
12Referral Guidelines Flashing lights and floaters Retinal holes and detachments – difficult to see with ophthalmoscope.Hx >6/52 Routine ReferralHx < 6/52 esp in under 55’s urgent OPD referralHx recent onset with decreased VA – URGENT A/E
13FiveA 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.
14Stye (abscess formation at root of lash) Meibomium cyst (Chalazion)StyeRoot of eye lash infectedPain tender lid swellingSteaming, epilation of lashABx dropsMeibomianBlockage of Meibomian glandsglands along tarsal plate.Tender, swollen upper or lower eye lid.Rx Abx and steamingMost 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
15Orbital cellulitis Preseptal cellulitis Preseptal Infection of tissues in front of orbitSymptomsFrontal headache, inability to open eyelid, systemic fever.SignsFacial cellulitis with gross swelling of eyelid, closure of lidWould expect full range of movement and normally good Va.CausesSinusitis in young children, cellulitis of lids from infected Meibomian cyst.ManagementImmediate referral to A/E and treated with oral/IV Abx.OrbitalLid swelling, eye proptosed, chemosis, limited ocular movements, difficulty opening eye. Abnormal pupil reaction. Optic disc swelling, sinus tenderness.FEVER, headaches diplopia and loss of vaOrbit is usually infected by neighbouring structures – often sinus.LIFE THREATENING – urgent referral. Admission IV abx.Orbital cellulitisPreseptal cellulitis
16SixA 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.
17Vernal Conjunctivitis Chemosis - Conjunctival swelling from allergy and excessive rubbingVernalOn 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 ChemosisNEXT slideRx antihistamine drops / oralOctrivine antistin quick acting, opticrom takes 24hr before useful, but effective if used regularly.AND BLEPHARITIS – NEXT SLIDE
18Oil secretion from Meibomian Glands Over secretion of oil from Meibomian glands causing blepharitisBurning, 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 dropsWHICH REQUIRES LID HYGIENE – NEXT SLIDEBlepharitis
19Lid Hygiene 150ml Cooled boiled water 1 tea spoon Baby shampoo Mix and store in fridge up to 1/52Using cotton bud – clean top and bottom lashes (as if putting on eye liner)Daily for 2/52 then decrease to twice a week indefinitely
20SevenA 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 diagnosisAcute glaucomaDentritic or bacterial ulcerIritisScleritis
21Episcleritis 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 RxIf persistent and severe referral for steroid drops.ScleritisV engorged deep scleral vessels. Can be confirmed as these vessels can not be moved with a cotton bud.Severe deep pain, headaches, photophobiaNot too common but associated with autoimmune systemic diseases, post herpes.Immediate referral to Eye cas for possible IV steroidsTHIS LEAVES DENTRITIC ULCER OR IRITIS – GO TO NEXT SLIDEScleritis
22Typically present with a red, photophobic eye, decrease in Va and tearing. Flourescien staining show branch of tree.Reduced corneal sensation in that eyeTissue test.Herpes simplex Virus can be 1 or 2.Rx Acyclovir 5 x daily and CT until no dentrites seen.Dendritic Ulcer
23Anterior Uveitis (Iritis) Particular bad caseUnreactive, irregular pupil as stuck down to lens (Posterior synechiae)Photophobic, red cliary injection and very painful.Blurred VaSlit lamp Ex, inflammatory cells in AC and KP on endotheliumRequires 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)
24EightAn 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
25Acute Angle Closure Glaucoma Acute red painful, throbbing eye. Haloes around lights, headache and nausea and vomitingNB Pt’s have been admitted for GI investigations for vomiting in past.Hazy cornea, intense injection around cornea. Mid fixed dilated pupilSTONY 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 injuryPt’s with Hx of drainage angle abnormalities.URGENT REFERRALDigital Tonometry
27NineA 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 listThese would includeCentral ret vien occCentral ret art occIschemic neuropathy – Temporal arteritisMacular haemorrhageVit haem2. Other condition to exclude is Giant cell arteritis3. 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.
28Central 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 spotAfferent pupillary defectVisual acutity perception of lightCausesEmboli from major arteries in head and from Left side of heart.Clots, Ca deposits, Inflammation from Giant cell arteritisRisk factorsOver age of 50Hypertension.Raised cholesterolDiabetesCarotid artery diseaseManagementUrgent referal to A/E, Immediate occular massage and lowering of intraocular pressure may improve outcome.
29Central 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
30Optic Neuritis/Papilloedema Think Young FemalesDecreased visual acuity RAPDPain on ocular movement.PapilleodemaVa and RAPD normalCausesRaised Intra cran pressure,Brain tumourhypertension.meningitis
31Examination 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
32RAPD (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
34Ophthalmoscope Practice Find tops tips for using ophthalmoscope in hand outGet into small groupsPractice !!!!!
35TenA 60 year lady complains of recent onset of distorted and blurred vision especially when reading the newspaper.What eye conditions do you suspect?
36Age related Macular degeneration CataractsDiabetic RetinopathyHypertension
37ARMD – wet & dryDry – 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
39WET Abnormal growth of blood vessels that leak blood and fluid. Causes scarring& permanent loss of central visionSigns – lines becomes wavy, door frames appear wonky.Onset is usually rapid.Early diagnosis is critical if sight is to be saved
41Risk Factors Increases with age Fhx / genetics Gender – more common in femalesSmokingObesityPoor nutrition – enc colourful vegCVDCaucasian
42TreatmentLucentis 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
44Diabetic Retinopathy Known as Background or Non-proliferative Hard exudates – yellow flecks deep in the retina reflecting leakage of incompetent pre capillary retinal arteriolesHaemorrhages – ‘red dots’ show mini blow outs of the diseased pre capillary arterioles
45ProliferativeThis 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
46GlaucomaAs 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 discNormal disc
47Disc Oedema with Hypertension Disc oedema with splinter haemorrhagesCaused from severe hypertension
49(removed for cosmetic purposes) Basal cell CarcinomaPapilloma(removed for cosmetic purposes)BBCAccounts for 90% of eyelid tumours.Most common in elderly and fair skin high levels of sun in younger individuals.Slow growing, rodent ulcerLoss of eye lashes, ulceration, dilated blood vessels, pearly lesion.Papilloma – removed for cosmetic purposes
50Cyst 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 ZeisSimilar 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
51Pinguecula 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 corneaPingueculaSimilar to pterygium but does not encroach the cornea.
52Watery eyes – epiphoraLSWOBabies refer after 15 months
53Entropian 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.EctropianExcess tearing, sore and irritable eyeCorneal damage from drying outAs a result of agingRx – lubricants and referral for corrective surgeryEctropian
54Xanthelasma Milia Xanthelasma Fatty deposits around the eyes Indication of hypercholesterolaemiaNo RxMiliaCrops of tiny white cystsNo treatmentMilia
55Rust 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 PerforationRequires removal – dependent on experience and skill.Benoxinate,Performed on slit lampRust RingRust 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
56Conjunctival Melanoma Pigmented LesionConjunctival MelanomaPigmented LesionConjunctival nevusBenign and unilateralCan be melanoma but very rare under age of 50Reassure and in some bad cases removal can be considered.MelanomaTumour on conjunctiva – pigmented nodule fixed to the scleraRare – seen in pt’s over 60
57Paediatric 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……
58What are they? If one eye has poor vision - eg Congenital Cataract High refractive errorPtosis – drooping eye lidOther pathology such as retinoblastoma2. The other if one eye is squinting
59SquintBrain 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
60Final QuestionMother 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 squintWhat do you do?
62What 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 problemsTropicamide – if need a clearer of view of fundusGlaucoma 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 unitArtificial Tear drops / ointment – there are loads – start with hypromellose, then progress to gel tears and lacri-lube at nightAntiviral ointment – I doubt you’ll prescribe without confirmation of herpetic infectionAntibiotic ointment / drops – next slide
63Chloramphenicol Ointment 1% - QDS Drops 0.5% - QDS Abraisions Dry eye syndromeSoften FB or rust ringEasier to apply if tube warmed in hand/pocket.Size of grain of riceDrops 0.5% - QDSBacterial infectionNo blurring of VaTo be stored in fridgeDO not use in SOFT contact lens use.Asses if can instil drops
64Fucithalmic 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.
65Chloramphenicol v Fusidic Mini ReviewReferenceGriffiths 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
66Local Services to Epsom Surrey Association for Visual Impairment (SAVI)TelEpsom and Ewell Club for the blindTelSwail House – Ashley Rd - Housing for visually impaired -
68References 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.