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

2. 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

3. 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

4. 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

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

6. 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

7. 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 ??

8. 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

9. 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)

10. 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)

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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. Questions / Comments

26. Thank You