Matt Edmunds Clinical Lecturer / Specialty Registrar Academic Unit of Ophthalmology University of Birmingham

 What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?  Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?  What possible emergency/ urgent eye conditions do you think need:  Immediate referral/today/tomorrow morning/clinic?  How should we access these/ advice OOH?

 The red eye  What to do about dry eyes/ watering eyes/ blepharitis  What to do about floaters and/ or flashes  What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?

 What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?  What mistakes do we make in our history- taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?

 Broad generalisation…….  Most patients will present with ‘red eye’  Significant proportion of red eye can be managed in primary care ▪ Whereas most ‘non-red eye’ pathology is likely to require secondary care input  Limitations  Not much training in eyes ▪ Year 4 MBChB at UoB: 5 days ophthalmology ▪ Few GP VTS posts in ophthalmology across Midlands  Lack of equipment  Pressurised for time

 Acute or gradual onset?  One or both eyes?  Is vision affected?  Discharge?  Purulent?  Watery?  Pain?  Sensitivity to light?  Contact lens wearer?  Previous episodes?  Industrial injury?  Associated systemic symptoms?

 Visual acuity (and idea of any recent changes)  Pupil reactions  Eye movements  Gross observations  Lid swelling and discharge / lash crusting  Distribution of any redness / obvious eye lesions  Corneal staining with fluorescein / FB  Comment on anterior chamber / cornea ▪ TIP: Ophthalmoscope on +20D  Optic disc / fundus  Not easy with ophthalmoscope  Please, at least try

 Can use book eg BNF/BMJ if snellen chart not available on wards  Snellen charts needed in practice

Hypermetrope (convex) Myope (concave) Almost emmetropic

 If unable to read top line on Snellen chart:

 Count fingers? (CF)

 If unable to read top line on Snellen chart:  Count fingers? (CF)  Hand movements? (HM)

 If unable to read top line on Snellen chart:  Count fingers? (CF)  Hand movements? (HM)  Perceive light? (PL)

 If unable to read top line on Snellen chart:  Count fingers? (CF)  Hand movements? (HM)  Perceive light? (PL)  No light perception (NLP)

Conjunctiva Limbus Iris Cornea Lower punctum Upper punctum Caruncle

Temporal Nasal Superior Inferior

 Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?  Dark room  Dim ophthalmoscope light  Smaller pupil setting  Get patient to look into distance  ?Pharmacologically dilate pupils  Mainly: have low expectations!

 What possible emergency/ urgent eye conditions do you think need:  Immediate referral/today/tomorrow morning/clinic?  How should we access these/ advice OOH?

 There may be disparity in sense of urgency  You may get a different response to a referral at different times of the day – appropriate  Please don’t ‘opt out’ of ophthalmology  Please always send a brief referral letter

 Same day  Acute glaucoma  Temporal arteritis (with definite ophthalmic symptoms)  Painful eye after cataract surgery  Painful or red eye after corneal graft  Painful or red eye in contact lens wearer  Orbital cellulitis  Suspected corneal infections  Could wait until next day  Uveitis  Zoster with eye involvement  Scleritis  If not resolving as expected  Conjunctivitis  Episcleritis  Via out-patient clinic  Blepharitis / Dry eye / Chronic grittiness or soreness  Entropion  Ectropion

 GCA with eye involvement  Temporal pain / jaw claudication / night sweats / weight loss / transient visual obscurations / visual disturbance  CRAO within past 24 hours  Sudden and persistent unilateral painless loss of vision  Orbital cellulitis  Significant chemical injury  Suspected penetrating eye injury / significant trauma  Retrobulbar haemorrhage  Acute glaucoma  Suspected endophthalmitis  Painful red eye / reduced vision / recent intra-ocular intervention

 Suspected retinal tear / detachment  Suspected vitreous haemorrhage  Suspected optic neuritis (unless GCA)  New onset diplopia  Unless 3 rd nerve palsy / complex CN palsy  Most trauma  Most red eye pathology

 Open for walk-in patients 365 days / year  No referral necessary  Accept all patients 9am – 7pm Mon-Sat / 9am-6pm Sun and Bank Holidays  Urgent care clinic available via triage nurse  Also have acute referral clinics at RHH / SGH  Limited number of clinic slots  Accept direct GP referrals  No emergency eye clinic at QEH

 On-call registrar via telephone overnight  Discuss emergency patients  Review patients on eye ward if necessary (Sheldon Block, City Hospital, Dudley Road)  Senior SpR (4 th on-call) will review patients in peripheral units if necessary

 Contact triage nurse at BMEC  Call on-call SpR (2 nd or 4 th on-call) at BMEC  Send to BMEC eye casualty  With a letter  If patient will arrive before closing time (7pm)

 The red eye!  What to do about dry eyes/ watering eyes/ blepharitis

 Up to 80% of eye casualties present with a red eye  Causes of a red eye can be roughly divided into two groups  Pain +/- blurring of vision  No pain and normal vision

 Most red eyes are due to conjunctivitis / blepharitis / dry eye  If you can confidently exclude ‘serious’ pathology  Oc. Chloramphenicol 1.0% QDS  Warm compresses  Lid hygiene  Lubricants PRN ▪ Celluvisc / Optive / Systane / Hyloforte / Xailin  Olapatidine BD (Opatanol) for allergic disease  Discuss / refer if not improving / resolving

Pain +/- blurred vision  Important differential diagnoses include:  Acute glaucoma  Corneal infections  Anterior uveitis (iritis)  Scleritis No pain  Differential diagnoses include:  Conjunctivitis  Episcleritis  Subconjunctival haemorrhage

 Eyelids  Conjunctivitis  Bacterial  Viral  Chlamydial  Allergic  Keratitis  Bacterial  (Marginal)  Viral  (Episcleritis) / scleritis  Acute anterior uveitis (iritis)  Angle closure glaucoma  Orbit  Orbital cellulitis  Trauma  Subconjunctival haemorrhage  Corneal abrasion  Corneal FB  Chemical burn

Chronic inflammation of the eyelid margins Causes Usually Staph aureus or epidermidis Associated with skin disease Acne rosacea Seborrhoeic dermatitis Symptoms SoreGritty Occasionally red eyes

Examination Hyperaemic lid margins Crusts on lashes Blocked meibomian gland orifices Meibomian cysts Complications Conjunctivitis Marginal keratitis Meibomian cysts

 Lid hygiene  Warm compresses  Gentle expression of lipids with a cotton tipped applicator  Gentle lid cleaning with a solution of sodium bicarbonate  Antibiotic ointment  Lubricants  Omega-3  Low dose tetracyclines  Antibiotics  Lipid soluble  Protease inhibitors

Ectropion In-turning of the lower lid Out-turning of the lower lid

Bacterial Viral Chlamydial Allergic Cicatrising

Causes Usually staphylococcus, streptococcus or haemophilus species Symptoms Slight discomfortRed, sticky eye(s) Visual acuity is not affected although slight blurring due to purulent exudation, which clears when discharge is blinked away Examination Generalised conjunctival injection with purulent discharge lashes may stick together

Causes Usually staphylococcus, streptococcus or haemophilus species Symptoms Slight discomfortRed, sticky eye(s) Visual acuity is not affected although slight blurring due to purulent exudation, which clears when discharge is blinked away Examination Generalised conjunctival injection with purulent discharge lashes may stick together

Complications Usually nil Treatment frequent antibiotic drops - instil hourly for 24 hours then qid for a week general hygiene by not sharing towels etc

Causes Usually adenovirus (self-limiting, but can also affect cornea - keratoconjunctivitis) Symptoms Red, watery eye(s) Gritty, uncomfortable feeling

Vision unaffected unless the cornea is involved Generalised conjunctival injection with watery discharge Follicles (lymphoid aggregates) in the tarsal conjunctiva Petechial conjunctival haemorrhages Enlarged pre- auricular lymph node Associated URTI

Complications Highly contagious Risk of epidemics Nosocomial transfer May last several weeks Small corneal opacities leading to photophobia and reduced vision Treatment Nil Antibiotic drops to prevent secondary bacterial infection General hygiene by not sharing towels etc

Red, watery eye(s) Vision unaffected Gritty, foreign body sensation Chronic Follicular reaction Usually young adults Sexually acquired Requires systemic antibiotics

Acute onsetRed, itchy eye(s) Chemosis (conjunctival oedema) Vision unaffected Type 1 hypersensitivity reaction Seasonal Perennial Often settles spontaneously Oral antihistamines Sodium cromoglycate / Olapatidine

Bacterial ViralAutoimmune Fungal

An ophthalmic emergency Causes Large range of gram positive or negative organisms Predisposing factors include Corneal abrasion Contact lenses (usually soft extended wear) Topical steroids Corneal anaesthesia (e.g. previous herpes zoster ophthalmicus)

Symptoms Red, sticky eyePainReduced visionPhotophobia Examination Conjunctival injection with purulent discharge Corneal abscess (yellow/white area on cornea) May be activity (cells) in anterior chamber

Complications Severe sight- threatening intraocular infection (endophthalmitis) Corneal perforationLoss of eye Treatment Admit Scrape cornea Gram stain Culture and sensitivities

Sterilisation phase Hourly antibiotics (usually monotherapy with a fluroquinolone) day and night for 2 days Hourly antibiotics by day for three days Cycloplegics Intraocular hypotensives Sub-conjunctival injections to be AVOIDED Healing phase Healing retarded in persistent inflammation Judicious use of topical glucocorticoids Treat ocular surface disease (dye eye, entropions, blepharitis)

Causes Herpes simplex type I (commonest) Symptoms Reduced vision - frequently Unilateral red eyePainPhotophobia Examination Conjunctival injection Classical branching dendritic (epithelial) ulcer staining with fluorescein Reduced corneal sensation Complications Corneal scarring May affect deeper corneal layers e.g. stroma (disciform keratitis) Corneal perforation

Complications DO NOT USE STEROIDS Treatment Secondary bacterial infection Ulcer may recur Geographical ulceration Antiviral ointment (e.g. aciclovir) tapering over a few weeks Dilate pupil

Idiopathic Infective Systemic disease

Anterior scleritis is sub-divided into Diffuse Nodular Necrotising Anterior scleritis is commonest but posterior involvement also occurs Inflammation of the outer (white) coat of the eye and can be a severe destructive, sight-threatening disease

Causes Majority idiopathic 40% associated with a connective tissue or vasculitic disease, commonest being rheumatoid arthritis Infections Varicella Zoster Acanthamoeba Bacterial endotoxins Symptoms Pain (may be so severe that it wakes the patient at night) Red eye(s)May be recurrentPain on EOM

Deep red colouration of anterior sclera - may be diffuse or localised Visual acuity may be normal Scleral thinning associated with bluish/black discolouration from underlying uveal tissue

Systemic corticosteroids/pulse d immunosuppression for severe cases Topical steroids as supplementary therapy Oral NSAIDs for mild cases Complications Visual loss Scleral thinning Perforation of the globe Optic disc and macular oedema

Uveitis Endophthalmitis (infection inside the eye)

Uveitis cannot be accurately diagnosed without the aid of a slit-lamp Causes Majority unknown, occurs usually in year age group May be associated with a systemic disease e.g HLA-B27, sarcoidosis May be associated with an infection e.g. herpetic, TB Symptoms Red eye (usually unilateral) Pain Blurred vision Photophobia NO discharge NOT sticky

Circumcorneal conjunctival injection Keratic precipitates (inflammatory cells) on corneal endothelium

Flare (albumin leakage from iris vessels) Inflammatory cells in the anterior chamber - hypopyon if severe Miosis Posterior synechiae (adhesions between iris and lens)

Complications May be associated with raised intraocular pressure (IOP) May become chronic and develop secondary cataract +/- macular oedema leading to reduced vision The condition is likely to recur and in either eye Treatment Dilate pupil to prevent ciliary spasm and break posterior synechiae Intensive topical steroids, initially 1-2 hourly then gradually reduce over next 4-6/52 In severe cases a subconjunctival injection of steroid +/- mydricaine (dilating agent) is necessary

Causes High hyperopia Advancing cataract NOT related to POAG Symptoms Nausea / vomiting Painful red eye Hazy vision Haloes around bright lights Examination Hyperaemia +++ Fixed mid- dilated pupil Hazy corneaEpiphora Complications Rapid and complete visual loss Aetiology is usually bilateral

Palpate the eye to approximate IOP

 What to do about floaters / flashing lights  Don’t panic – most cases will be a PVD  Could it be migraine??  If there is a retinal detachment – at BMEC:  ‘Macula on’ – hours  ‘Macula off’ – 5-7 days

Causes Spread of local infection Sinusitis Eyelis Symptoms FeverPainful red eyeEyelid swellingReduced visionDiplopia Examination Engorged conjunctival vessels Conjunctival chemosis Restricted EOMProptosisRAPD Complications Optic nerve compression Exposure keratitis Rapid and complete visual loss Intra-cranial spread

 At 5 pm on a Thursday afternoon…….  68 year-old woman  Previous right eye retinal detachment  2 days history of left flashing lights / floaters  Right VA 6/36, Left VA 6/9  Pupil reactions normal

 At 11 am on a Friday morning…….  76 year-old woman  Hypermetrope  ‘Optician says I have cataracts in both eyes’  2 months intermittent left eye pain, redness and hazy vision  Right VA 6/12, Left VA 6/24  Pupil reactions normal

 At 9 am on a Monday morning…….  26 year-old man  Awoke this morning with a painful, red left eye  ‘Short-sighted’  Slept in contact lenses overnight from Saturday  Right VA 6/12, Left VA 6/18 (wearing old specs)  Pupil reactions normal

 At 2 pm on a Monday afternoon…….  26 year-old man  1 week history of red, gritty eyes and discharge  Partner had sore throat and ‘flu symptoms  Baby daughter recently had red eyes  Right VA 6/9, Left VA 6/9  Pupil reactions normal

 At 6 pm on a Tuesday afternoon…….  36 year-old man  Recent nose bleeds and short of breath  Difficulty with left hearing  Past 3 days unable to sleep with painful, red right eye and some photophobia  No response with paracetamol /ibuprofen  Right VA 6/12, Left VA 6/9  Pupil reactions normal

 At 10 am on a Tuesday morning…….  76 year-old woman  Feeling generally unwell, off food, losing weight, difficulty sleeping  Night sweats 2 weeks  Headache  Right VA 6/9, Left VA 6/9  Pupil reactions normal

 Purulent discharge = bacterial infection  Photophobia = keratitis, uveitis  Reduced vision = keratitis, uveitis, angle closure glaucoma  Pain = scleritis, angle closure glaucoma, keratitis, uveitis  Hazy cornea = angle closure glaucoma, keratitis, uveitis  Contact lens wearer and sticky eye = must exclude bacterial keratitis

 VA and pupil examination are crucial  Refer any CL wearer with red eye or pain  Become familiar with a limited range of lubricant drops and stick to them  If giving drops >4x/day then they should be PF (preservative free)

 Please don’t prescribe ocular topical steroids in primary care – great potential for ‘disaster’  Please do provide topical steroids if ongoing eye review  Squinting children  Recent onset: refer urgently to eye cas  Long-standing: refer to clinic  Temporal arteritis  No visual symptoms – refer to rheumatology  Visual symptoms – refer to ophthalmology