2You are not alone! A very popular topic How much time at medical school?What do the acuity numbers mean!
3Special 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.
4Contact 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?
5Examination Snellan chart, 3m or 6m, simple text for near vision, PinholesFields, remember red and the quality of the red, simple 4 quadrant testing.Pupils: a bright torch and magnifying glassSquintMovementsOpthalmoscopy: Start at 10, red reflex?, green filter enhances blood vessels, dilate prn, risk of acute closed angle glaucoma remote.
6Clinical classification Red eyeLids and tearsSlow visual loss in the quiet eyeTraumaSquints, new and congenital, rare movement disorders…..(then a rare specialist rag bag)
7Red 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 (?)
8ConjunctivitisViralOften 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.
9Conjunctivitis Chlamydia Mucopurulent, cornea inflamed, visual loss. Often with STD. Permanent damage possible, topical and? systemic tetracyclines. Refer.InfantsLess than one month is notifiable disease - any cause. May lead to scarring and permanent damage. Refer most.AllergicItching and discomfort. Chemosis and visual acuity loss possible. Papillae and if big cobblestones. Cromoglycate may take days to start to work if bad.
10Episcleritis / 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.
11Corneal ulcersAny infection, Abrasion, topical steroids, contact lens use.PAIN. - Except zosterMay 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.
12Anterior uveitisThe 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.
13Acute 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.
14Lids and tears Chalazion = meibomnian cyst. In the lid. Warm compresses and chloramphenicol. Persistent - incise.Recurrent: ? DM, ? blepharitis, ? roseacea.Can cause astigmatism from pressure.
15StyeAn infection of lash follicle. May be head of pus - nick with needle. Or warm compresses and chloramphenicol.
16Marginal cystsNon infected cysts from sweat or sebaceous lid glands, if a problem can often be simply treated with a nick with a needle - small.
17BlepharitisCommon, 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
18Acute dacrocystitisMedial inflammation over lacrimal sac. Refer, systemic therapy and topical urgently.
19Orbital cellulitisLife 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
20EctropionWatery eye.. Laxity from age or nerve palsy. Ointment and refer for LA operation to correct.EntropionCommon especially in the elderly. Scarring from the lashes.Often results from blepharitis or chronic conjunctivitisRefer
21Ingrowing lashesDamage to lids. May be removed but will often need electrolysis or cryocautery to prevent recurrence.
22Watering eyesDifferential diagnosis.-your homework!Dry eyesCommon,Remember to treat associated blepharitis
23An easy list really as they all need specialist assessment! Sudden visual lossAn easy list really as they all need specialist assessment!
24Retinal detachmentFloaters, photopsias, the shadow or curtain across the sight.Optic neuritisMore women, pain on moving the eye, central scotomaPosterior vitreous detachmentAged 50+, flashing lights, floatersVitreous haemorrhageFloaters, red haze may be present. Red reflex absent.
25Disciform macular degeneration Sudden disturbance of central vision.Vascular occlusionsField loss. Diabetes, hypertensionMigraineYouth, headache, zigzag lines, multicoloured lights.Cerebrovascular diseaseElderly, bilateral loss.
26Slow visual loss Refer to optician then ? refer. Cataracts Corneal opacitiesMacular problemsRetinal problems