1. OPHTHALMOLOGY UPDATE Ajay Bhatnagar Consultant Ophthalmologist
Wolverhampton Eye Infirmary and Walsall Manor Hospital

2. Overview Acute eye problems in community setting
Examination
Differential diagnosis
Management guidance
Guidance / referral pathways for a few common eye conditions
Watery eye / dry eye / Blepharitis
Flashes and floaters
AMD
Diabetic retinopathy

3. Acute eye problems in community setting
The Red Eye
Common causes
Lids
Blepharitis
Ocular surface
Tear film
Conjunctiva
Cornea
Intraocular causes
Anterior uveitis (iritis)
Acute angle closure glaucoma

4. Acute eye problems in community setting
The Red Eye
History
Lids
Sore, crusty eye lid margins/eyelashes. Long history (Blepharitis)
Ocular surface
Tear film – grittiness (Dry eye)
Conjunctiva – grittiness, watery / sticky disch, contact history (Conjunctivitis)
Cornea – Pain ++. h/o FB, Contact lens (Ulcer / Abrasion)
Intraocular causes
Anterior uveitis (iritis) – pain++, tenderness, photophobia
Acute angle closure glaucoma – pain++, reduced vision

5. Acute eye problems in community setting
The Red Eye
Examination
Lids
Crusty eye lid margins/eyelashes. Periocular skin
Ocular surface
Tear film – Tear meniscus……fluorescein dye
Conjunctiva – generalised congestion, tarsal conj., cornea is clear
Cornea – Corneal haze, fluorescein dye
Intraocular causes
Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, hypopyon
Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil

6. Acute eye problems in community setting
The Red Eye
Examination
Lids
Crusty eye lid margins/eyelashes. Periocular skin
Ocular surface
Tear film – Tear meniscus……fluorescein dye
Conjunctiva – generalised congestion, tarsal conj., cornea is clear
Cornea – Corneal haze, fluorescein dye
Intraocular causes
Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon
Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil

7. Acute eye problems in community setting
The Red Eye
Examination
Lids
Crusty eye lid margins/eyelashes. Periocular skin
Ocular surface
Tear film – Tear meniscus……fluorescein dye
Conjunctiva – generalised congestion, tarsal conj., cornea is clear
Cornea – Corneal haze, fluorescein dye
Intraocular causes
Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon
Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil

8. Acute eye problems in community setting
Examination
Lids
Crusty eye lid margins/eyelashes. Periocular skin
Ocular surface
Tear film – Tear meniscus……fluorescein dye
Conjunctiva – generalised congestion, tarsal conj., cornea is clear
Cornea – Corneal haze, fluorescein dye
Intraocular causes
Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, hypopyon
Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated pupil

9. Acute eye problems in community setting
Management
Treatable in primary care
Blepharitis - lid hygiene, topical lubricants
Dry Eye - Topical lubricants (drops / gel + ointment at night)
Conjunctivitis (Chlamydia – GUM)
Refer to secondary care
Corneal ulcer (?abrasion)
Corneal problems in CL wearers
Anterior uveitis (early treatment – quicker response…….topical steroids ……..recurrent AAU)
Acute angle closure (ophthalmic emergency)

10. Overview Acute eye problems in community setting
Examination
Differential diagnosis
Management guidance
Guidance / referral pathways for a few common eye conditions
Watery eye / dry eye / Blepharitis
Flashes and floaters
AMD
Diabetic retinopathy

11. Watery Eye

12. Watery Eye Excessive tear production Problems with tear outflow
Any irritation to ocular surface
(ingrowing eyelash, blepharitis, “cold wind”, allergy)
“Dry Eye”
Problems with tear outflow

13. Watery Eye Excessive tear production Problems with tear outflow
Any irritation to ocular surface
(ingrowing eyelash, FB, “cold wind”, allergy)
“Dry Eye”
Problems with tear outflow
Eyelid malposition (punctal eversion / stenosis, ectropion)
Blocked tear duct

14. Watery Eye When to refer Treatable in primary care
Persistent, constant watering eyes
Punctal stenosis, trichiasis – minor op
Punctal / lid malposition – oculoplastic surgery
Suspected blocked tear duct – oculoplastic surgery
Treatable in primary care
Dry eye , blepharitis

15. Watery Eye When to refer Treatable in primary care
Dry eye
Mild to moderate
topical lubricants
Drops / Gel / Ointment
Preservative-free drops
Moderate to severe
Punctal occlusion
Refer to eye clinic
Blepharitis
Mild to moderate
Lid hygeine
Topical lubricants
Moderate to severe
Oral doxycycline
Refer to eye clinic
When to refer
Persistent, constant watering eyes
Punctal stenosis, trichiasis – minor op
Punctal / lid malposition – oculoplastic surgery
Suspected blocked tear duct – oculoplastic surgery
Treatable in primary care
Dry eye , blepharitis

16. Watery Eye When to refer Treatable in primary care
Persistent, constant watering eyes
Punctal stenosis, trichiasis – minor op
Punctal / lid malposition – oculoplastic surgery
Suspected blocked tear duct – oculoplastic surgery
Treatable in primary care
Dry eye , blepharitis
Managing patient expectations

17. Overview Acute eye problems in community setting
Examination
Differential diagnosis
Management guidance
Guidance / referral pathways for a few common eye conditions
Watery eye / dry eye / Blepharitis
Flashes and floaters
AMD
Diabetic retinopathy

18. Flashes and Floaters
Posterior Vitreous Detachment
(PVD)
PVD Retinal D

19. Flashes and Floaters Urgent referral to eye clinic
Sudden onset, multiple floaters
Recent onset, multiple flashes of light
“Curtain” / visual field defect
Non-urgent / No referral to eye clinic
Long duration of floaters
Occasional flash of light

20. Overview Acute eye problems in community setting
Examination
Differential diagnosis
Management guidance
Guidance / referral pathways for a few common eye conditions
Watery eye / dry eye / Blepharitis
Flashes and floaters
AMD
Diabetic retinopathy

21. AMD Dry AMD Wet AMD Gradual decline in vision Central vision impaired
Long standing / slowly worsening distortion in central vision
Management
Dietary supplements
Supportive care (LVA, NGOs, CVI)
Wet AMD

22. Wet (neovascular) AMD Vision loss is more rapid Warning symptoms
Recent onset distortion of central vision
Recent onset blurred central vision
Referral pathway
Direct referral from Optom to fast track macula clinic (Fax to WEI)
Management
Intravitreal injections
Dietary supplements
Supportive care (LVA, NGOs, CVI)

23. Overview Acute eye problems in community setting
Examination
Differential diagnosis
Management guidance
Guidance / referral pathways for a few common eye conditions
Watery eye / dry eye / Blepharitis
Flashes and floaters
AMD
Diabetic retinopathy

24. Diabetic Retinopathy All patients with DM – screened by DESP
Patients with “referable retinopathy” are seen in hospital eye clinics
Asymptomatic patients picked up DR at routine eye test:
Are they being screened by DESP
Are they already under care of HES? (WEI / WMH)
Please write to the concerned Consultant
Management
Laser treatment – WMH / WEI
Intravitreal injections for DMO (WEI only)
How can primary care team help?
Control of systemic risk factors – sugar, BP, cholesteral
Fenofibrate?

25. In summary Red, painful eye
Differential diagnosis
Which of these patients can be treated within primary care and identifying those that need urgent referral?
Management and referral pathways for some common eye conditions
Watery eye
Flashes and floaters
AMD DR

26. Questions / Comments

27. Thank You