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

Patient 1 70 year old female Floaters – few months VA – 6/6 BE Eye exam: unremarkable Amsler – “some distortion” Urgent referral to eye casualty (WEI) Routine referral to WEI Routine referral to WMH Referral to wet AMD fast track clinic e. Any other

Patient 2 60 year old female c/o: sharp pain LE 2/12 (off and on) VABE 6/6. IOP WNL Eye exam WNL. Healthy discs Visual fields: defects BE Urgent referral to eye casualty (WEI) Routine referral to WEI Routine referral to WMH Any other

Patient 3 50 year old male Reduced VA BE (longstanding DR) Asymptomatic IOP: RE 23 LE 25 Left disc looks glaucomatous Urgent referral to eye casualty (WEI) Routine referral to WEI Routine referral to WMH Any other

Aim of today’s talk Refer the appropriate patient Appropriate time frame To the appropriate service

Some common conditions Cataract POLCV guidelines Direct cataract referral to hospital of patient’s choice Avoid referring using GOS18 Glaucoma IOP referral refinement Refer – routine to WMH Known patients with glaucoma……refer to original consultant at WMH / WEI

Some common conditions AMD Fast track Macula Clinic (Fax to WEI) Symptoms Sudden decrease in VA Spontaneously reported recent onset distortion Signs Macular Hge / lipid / oedema Routine referral to local eye clinic ??

Some common conditions Flashes and floaters Self-reported, recent onset symptoms Schaffer sign (“tobacco dust” in vitreous cavity) Dilated fundus exam (digital wide field lens) Refer to ARC if suspicion of retinal tear / detachment 24 hr referral –definite RD / retinal tear 72 hour referral – PVD related symptoms (<1/12 duration) with pigment in vitreous cavity. Others ?? Routine referral Long standing symptoms / occ flash or floater

Some common conditions Reduction in vision: <48 hrs onset…….ARC (to be seen within 24 hrs) RD (includes retinal tear with no RD) Retinal vascular occlusion Optic neuritis / AION Unexplained sudden loss of vision <1/12 duration……ARC (to be seen within 72 hours) >1/12 duration …..refer to eye clinic (GOS 18)

Some common conditions Diplopia Monocular vs binocular Binocular diplopia <1/12 duration with no other symptoms – 72 hrs ARC >1/12 duration – refer via GOS 18 Exception: Painful III cranial nerve palsy (ptosis, limitation of EOM, dilated pupil)

Some common conditions The Red Eye Common causes Lids Ocular surface Tear film Conjunctiva Cornea Intraocular causes Anterior uveitis (iritis) Acute angle closure glaucoma

Some common conditions 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

Some common conditions 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

Some common conditions 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

Some common conditions 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

Some common conditions 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)

Some common conditions The Red Eye <24 hrs to ARC Ocular emergencies: C. ulcer, anterior uveitis, acute angle closure <72 hrs to ARC “severely” symptomatic patient due to blepharitis / dry eye / keratoconjunctivitis (?) / episcleritis / ?scleritis Referral via GOS 18 (soon appt) Severe lid margin abnormalities (entropion with lashes rubbing the cornea) Referral via GOS 18 (routine) Relatively minor symptoms and signs

Some common conditions Watery eye GOS 18 referral (rarely needs anything other than a routine appt) Examine lid margin (entropion / ectropion / blepharitis) Puncta (stenosis / apposition to globe) Tear film (meniscus / debris) Ocular surface (corneal PEEs)

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

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

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

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

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

Some common conditions Diabetic retinopathy All referrals to HES should ideally come via DESP If DR is noticed as part of routine ST: Check if pt already under DESP / HES (WMH / WEI) Referral needed / not??.....depends on multiple factors GOS 18 (routine / soon) to the patient’s local unit Vitreous Hge in a patient with DM Prev established PDR with PRP, no RD, ongoing FU Inform via urgent letter to the patient’s usual place of FU Not under care of ophthalmology service for DR Recent onset ….ARC (24 hr / 72 hr referral) Long duration….GOS 18 (soon)

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