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

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

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

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

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

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

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

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

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)

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

Watery Eye

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

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

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

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

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

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

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)

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

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?

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

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