-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
1/41
OP2CPD
Clinical Practice Development
Watery, itchy & gritty eye(s)
Mark Dunne & Bhavna Prajapati
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
2/41
Learning objectives
This lecture has been written to teach you:
A problem-orientated approach to a patient complaining of watery, itchy &gritty eye(s) or foreign body sensation
What you should ASKLOFTSEA, laterality, other symptoms (soreness, irritation, pain,photophobia, blurred vision), ocular history, medical history, family
historyWhat you should LOOK FOR
Visual acuity, external examination (eyelids, tears, lacrimal drainage,conjunctiva, cornea)
Further procedures (slit lamp biomicroscopy with Fluorescein, eyelid
eversion & dry eye tests such as TBUT, tear meniscus, Schirmer test,Lissamine green test)
About the PLANTreatment, advice, referral urgency (immediate, same day, urgent1
week, urgent2 weeks, soon1 month, routine)
Factors that influence referral
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
3/41
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
4/41
Revision tips
Exams WILL test you on:
What you need to ASK
What you need to LOOK FOR
SYMPTOMS & SIGNS that indicate
serious disease & raise referral
urgencySYMPTOMS, SIGNS & REFERRAL
URGENCIES of some serious eye
diseases
Concentrate on information given in:
BLACK TYPE SCRIPT
PURPLE TYPE SCRIPTNo need to revise:
Lists of diseases shown in BLUE
TYPE SCRIPT
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
5/41
SOAP (Revision)
Subjective
Case history
ASK for
Symptoms & signsObjective
LOOK for
Signs
Analysis
Differential diagnosis
During subjective & objective
Plan
Advice/treatment/referral
Urgency
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
6/41
Legal requirements (Revision)
This lecture:
Applies SOAP (problem-
orientated approach)
Leads to a more purposefulexamination
Examination MUST also meet legal
requirements
Cover all oculovisual systems:
VisualBinocular
Refractive
Ocular health
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
7/41
Overview
Many conditions present with WATERY, ITCHY or
GRITTY EYE(S)
Allergic conjunctivitis, dry eye, blepharitis,
ectropian, trichiasis, age-related nasolacrimal
duct obstruction, punctal stenosis, foreign body(on cornea, under eyelid), corneal ulcer
Note:These complaints suggest an ocular surface
problem, - so slit lamp examination required
with systematic examination of eyelids, tears,
lacrimal drainage, conjunctiva and cornea(including fluorescein instillation)
Think of commonest conditions first (eg allergic
conjunctivitis) but also consider rarer conditions
(eg corneal ulcer)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
8/41
LOFTSEA (Revision)
Location & laterality
OnsetFrequency & occurrence
Type & severity
Self-treatment (effectiveness)
Effect on patient
Associated or secondarysymptoms
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
9/41
Subjective (ASK)presenting symptoms
Watery eye(s)?Examples: allergic conjunctivitis, dry
eye, blepharitis, ectropian, trichiasis,
age-related nasolacrimal duct
obstruction, punctal stenosis, foreignbody (on cornea, under eyelid),
corneal ulcer,
Itchy eye(s)?
Examples: allergic conjunctivitis, dry
eye
Gritty eye(s)?Examples: dry eye, blepharitis
Foreign body sensation?
Examples: dry eye, blepharitis,
trichiasis, foreign body (on cornea,
under eyelid), corneal ulcer
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
10/41
Subjective (ASK)notes on presenting symptoms
Often most common but least serious
complaints
Watery eye(s)think about:
Reflex tearing caused by irritation
(dry eye can cause irritation)Lacrimal drainage problem in old
age
Itchy eye(s)think about:
Often due to allergic conjunctivitis
Ask if problem is seasonal
Gritty eye(s)think about:
Often due to dry eyes associated
with chronic blepharitis
Foreign body sensation?
Ask if something blew into eye
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
11/41
Subjective (ASK)laterality (LOFTSEA)
One eye?
Examples: ectropian, trichiasis,
age-related nasolacrimal duct
obstruction, punctal stenosis,
foreign body (on cornea, under
eyelid), corneal ulcer
Both eyes?Examples: allergic conjunctivitis, dry
eye,blepharitis, ectropian,
trichiasis, age-related nasolacrimal
duct obstruction, punctal stenosis
Caution:
The most serious conditions (eg
corneal ulcer) tend to affect one
eye
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
12/41
Subjective (ASK)Other symptoms (LOFTSEA)
Sore or irritated eyes?
Examples: allergic conjunctivitis, dry
eye, blepharitis,ectropian,
trichiasis,foreign body under eyelid
Most relevant to watery eye(s)Pain & photophobia?
Examples: foreign body on cornea,
corneal ulcer
Blurred vision?
Examples: dry eye, foreign body on
cornea, corneal ulcerNote:
Pain, photophobia & blurred
vision indicate serious problem
or raise referral urgency
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
13/41
Contact lens wear
Risk factor for corneal abrasion
or ulcer that may cause foreign
body sensation or watery eye
Allergy to cleaning solutions may
cause itchy eyes (allergic
conjunctivitis)
Use of eye drops
Allergy to these may cause itchy
eyes (allergic conjunctivitis)Previous eye surgery
A broken suture may cause
foreign body sensation or watery
eye
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Subjective (ASK)ocular history
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
14/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Subjective (ASK)medical history
Asthma, eczema, hay fever?
Indicates allergicconjunctivitis, causing itchy
eyes, in a person prone to
allergies
Rheumatoid arthritis
May be associated with dry
eye & non infectious corneal
ulcer
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
15/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Subjective (ASK)family history
Hayfever?There is often a family
history of hay fever in
sufferers of allergic
conjunctivitis
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
16/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)visual acuity
Referral letters require:
Unaided distance visionVisual acuity distance and
near
Previous visual acuity
Pinhole test
Rules out ametropia if blurred
vision is reported
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
17/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)binocular system
Covers legal requirements
Of little diagnostic value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
18/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)pupil responses
Covers legal requirements
Of little diagnostic value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
19/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)external
Systematic examination of
eyelids, tears, lacrimal
drainage, conjunctiva,
cornea
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
20/41
Objective (LOOK FOR)external (eyelids)
Slit lamp examination preferable
Blepharitis
Lid swelling (if severe), red lid
margins, blocked tarsal gland
openings, scales on lashes,
loss of lashes
Causes watery eye(s), gritty
eye(s) & foreign body
sensation
(Source: Kanski)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
21/41
Objective (LOOK FOR)external (eyelids)
Slit lamp examination preferableEctropion
Lower eyelid turned outwards
Lacrimal puncta held in wrong
position
Causes watery eyes
(Source: Kanski)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
22/41
Objective (LOOK FOR)external (eyelids)
Slit lamp examination preferableTrichiasis
Inturned eye lashes
Often due to blepharitis
Causes watery eye(s) &
foreign body sensation
(Source: http://dro.hs.columbia.edu/op1/trichiasis2b.jpg)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
23/41
Objective (LOOK FOR)external (tears)
Slit lamp examination with
Fluorescein preferable
Dry eye
Unstable tear film (various
signs including poor TBUT,
poor tear meniscus, frothing
of tears near lid margin)
Causes watery, itchy & grittyeye(s) plus foreign body
sensation(Source: Kanski)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
24/41
Objective (LOOK FOR)external (lacrimal drainage)
Slit lamp examination preferablePunctal stenosis or nasolacrimal
duct obstruction
Main sign is epiphora
(excessive tears)
Causes watery eye(s)
(Source: Kanski)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
25/41
Objective (LOOK FOR)external (conjunctiva)
Slit lamp examination with Fluorescein
preferable
Fluorescein staining
Superficial punctate staining on bulbar
conjunctiva may occur with dry eye
Check for foreign bodyMild redness/injection
Bulbar
Examples: allergic conjunctivitis, dry
eye, trichiasis
Move over scleraLimbal
Examples: foreign body on cornea,
corneal ulcer
Suggests more serious cause
(unreliable sign)
(Source: http://en.wikipedia.org/wiki/Allergic_conjunctivitis)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
26/41
Objective (LOOK FOR)external (conjunctiva)
Slit lamp examination preferable
Swelling/oedema
Example: allergic conjunctivitisDischarge
Watery (clear)
Examples: allergic
conjunctivitis
Mucopurulent (yellow, pus-like)Examples: corneal ulcer
(infectious)
(Source: http://en.wikipedia.org/wiki/Allergic_conjunctivitis)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
27/41
Objective (LOOK FOR)external (evert lids)
Slit lamp biomicroscopy with
Fluorescein preferable
Check for foreign body under eyelid
Pull down lower lid as well
Papillae (lid roughness)
Stain with fluorescein
Indicates allergic conjunctivitis
(CCLRU grading scales)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
28/41
Objective (LOOK FOR)external (cornea)
Slit lamp examination with Fluorescein
preferable
Check for foreign body on cornea
Fluorescein staining
Superficial punctate staining mayoccur with dry eye or allergy to
contact lens solutions
Can reveal corneal abrasion
caused by foreign body or trichiasis
Can stain corneal ulcer
Exposure staining may be caused
by ectropian
Epithelial opacity/stromal infiltrate
Indicates corneal ulcer
(Source: Kanski)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
29/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)internal examination
Covers legal requirements
Of little diagnostic value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
30/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)Refraction & near add
Refraction
Could carry out pinhole testover current Rx
Could over-refract current Rx
Rules out ametropia if blurred
vision is reported
Otherwise of little diagnostic
value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
31/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination
(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)Tonometry
Covers legal requirements
Of little diagnostic value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
32/41
Case History
(all systems)
Visual acuity
(visual, refractive, ocular health)
Cover test, motility, convergence
(binocular)
Pupil responses
(binocular, ocular health)
Ophthalmoscopyexternal & internal
(ocular health)
Refraction & near add determination
(refractive)
Tonometry
(ocular health)
Visual fields
(visual)
Objective (LOOK FOR)Visual fields
Covers legal requirements
Of little diagnostic value here
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
33/41
Analysisdifferential diagnosis
During subjective and objective
parts of SOAP
Will cover some examples in
tutorials next week
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
34/41
PlanTreatment/advice
Examples: allergic conjunctivitis, dry
eye, blepharitis, foreign body (on
cornea, under eyelid)
Note:Consider pharmaceutical options
with allergic conjunctivitis and dry
eye
Advice on lid hygiene with
blepharitis
Carefully remove foreign body with
cotton bud (under topical
anaesthesia if necessary)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
35/41
PlanReferral (immediate)
Example: corneal ulcer
Note immediacy of :
Corneal ulcer, regardless
of cause (to exclude
bacterial keratitis)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
36/41
PlanReferral (same day)
Example: foreign body (oncornea, under eyelid)
Note urgency of:
Foreign body that is
distressing to patient and
cannot be removed
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
37/41
PlanReferral (urgent1 week)
Examples: persistent allergic
conjunctivitis (>2/52), dry eye (if severe
and patient has rheumatoid arthritis),
unexplained foreign body sensation (withpain, photophobia or blurred vision)
NOTE urgency of :
Allergic conjunctivitis if persists for
over 2 weeksDry eye with rheumatoid arthritis
(suggests hyposecretive dry eye e.g.Sjgrens syndrome)Unexplained foreign body sensationwith pain, photophobia or blurredvision
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
38/41
PlanReferral (urgent2 weeks)
Examples: ectropion (if evidence ofcorneal exposure), trichiasis (if evidence
of corneal erosion)
NOTE urgency of :
Ectropion & trichiasis if there is
evidence of corneal exposure/erosion(Fluorescein staining)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
39/41
PlanReferral (soon1 month)
Examples: trichiasis (no evidence of
corneal erosion), unexplained foreign
body sensation (with out pain,photophobia or blurred vision)
Note urgency of :
Trichiasis where there is no
evidence of corneal exposure (no
Fluorescein staining)
Unexplained foreign bodysensation (with out pain,
photophobia or blurred vision)
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
40/41
PlanReferral (routineno specified time)
Examples: dry eye (if not severe and there is no
rheumatoid arthritis), blepharitis (if concerned),
ectropion (if patient wants surgery), age-related
nasolacrimal duct obstruction , punctal stenosis,
isolated epiphora, epiphora with recurrent
conjunctivitisNote referral of:
Dry eye that is not severe or without
rheumatoid arthritis
Blepharitis that persists despite lid hygiene
Ectropion if patient wants surgeryEpiphora due to age-related nasolacrimal
duct obstruction or punctal stenosis
Isolated epiphora or epiphoral with recurrent
conjunctivitis
-
8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)
41/41
You should now understand:
How to approach a problem-orientated eye examination on a person presenting with
watery, itchy or gritty eye(s) or, maybe, foreign body sensation
That these symptoms are often the most common but least serious complaints
That most of the required tests relate to external eye examination to investigate an
ocular surface problem
That additional procedures should include slit lamp biomicroscopy with Fluorescein,
eyelid eversion & dry eye tests (TBUT, tear meniscus, Schirmer test, Lissamine green
test)
That unexplained foreign body sensation requires referral (urgent if it occurs with
blurred vision, pain or photophobia)
That referral urgency is raised when there is (1) pain, photophobia or blurred vision
and (2) evidence of corneal exposure; All of these point to a possible corneal ulcer