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

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Presentation on theme: "Jane Goodwin BSc MSc Nurse Practitioner in Primary Care and Ophthalmic PwSI (practitioner with specialist interest)"— Presentation transcript:

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.

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