EYE PROBLEMS IN GENERAL PRACTICE

MAZHAR KHANGeneral practitioner

Heaton Medical Practice

Why is ophthalmology important in

General Practice ?

Expect 2 - 5 % of all GP consultations to be

eye related

• What do you do when you see a patient with new onset AF who suddenly wakes up in the morning with loss of vision in one eye?

• What do you do when you see an elderly woman with nausea/vomiting? Your working diagnosis is Gastroenteritis but she has a rt painful red eye. Is it just conjunctivitis?

• A patient with Rheumatoid Arthritis has been complaining of sore, gritty eyes for a week. You have tried ocular antibiotics and its not getting better. Is there something else going on?

General Practice

• Infective Conjunctivitis 44%• Allergic Conjunctivitis 15%• Meibomian Cyst 8%• Blepharitis 5%• Cataract 4.8%• Abraision/ F body 3%• Glaucoma 2.3%• Stye 2%• Macular disease 1.1%• Ant Uveitis 1.1%• No abnormality 1.8%• Other conditions 11.9%

A & E

• Foreign body 29%• Corneal abrasion 15%• Eye injury/trauma 15%• Infective Conjunctivitis 9%• Allergic Conjunctivitis 3%• Lid inflammation 3%• Other conditions 26%

Things to have in the clinic

• Snellen Chart• Ophthalmoscope• Fluorescein• Pen-torch with cobalt filter• Pin hole• Tropicamide 1% / Cyclopentolate 0.5/1%• Phenylepherine 2.5% • Amsler Grid• Local anaesthetic – Benoxinate/ Amethocaine

Anatomy of the human eye

Good history taking is vital

• History of presenting ophthalmic complaint/s

• Past ophthalmic history is important

• Current medical problems/ medications

• Past medical history could hold the clue

Basic ophthalmic examination

• Visual acuity for distance (Snellen chart/ Sheridan -Gardner test) and reading (near vision testing card)

• Visual fields by confrontation method

• Colour vision by using Ishihara’s chart

• Eye lids, lid margins, eye lashes

• Eye surface – conjunctiva, cornea, iris, sclera/ episclera

• Anterior chamber using a slit-lamp

• Pupils – not just PERLA

Basic ophthalmic examination

• Extra-ocular movements

• Examination of ocular media

– Dark room– Use a mydriatic– Cornea– Lens– Red reflex– Vitreous– Retina (optic disc, cup: disc ratio, arteries, veins,

exudates/hemorrhages, macula)

READY FOR SOME EYE SCENARIOS ?

SCENARIO 1

This 42 yr old patient presents with a 2 day Hx/o gritty, red lt eye which has become sticky over the last 24 hrs. His rt eye doesn’t feel right today as well. His vision is normal

• What is the diagnosis and etiology?• What are the clinical features you can see?• What other similar conditions should you differentiate it from?• How would you treat this patient?• How would you manage sticky eyes in babies?

Viral Conjunctivitis

Follicular changes Hemorrhagic changes

Allergic Conjunctivitis

                             

Perennial conjunctivitis

Vernal conjunctivitis

Atopic conjunctivitis Giant papillary conjunctivitis

SCENARIO 2

This patient attended his GP with a sore red eye and was treated with drops containing both a steroid and an antibiotic preparation. Three days later he returned saying his vision was blurred and his eye was more painful and intolerant to light

• What can you see on examination & what is the diagnosis?• What is the cause of this condition?• What stain has been used here? Which stain would be more usual to use?• What are the possible complications?• How would you manage this patient?• Is there any treatment that you would avoid in this condition?

Corneal Ulcer

Non infective infective - Contact lens - Trauma bacterial viral fungal protozoal - Previous corneal problems

ALL CORNEAL ULCERS SHOULD BE REFERRED URGENTLY DUE TO SIGHT THREAT

scenario 3

This 68 yr old patient presented to his GP with eye irritation and redness often worse when his central heating is on

• What tests are being performed in the above diagram and how are they done?

• What is the condition and its causes?• How do you treat this condition?

Scenario 4

This 19 yr old medical student complains of irritation of the eye lids. It has become much worse recently while studying for exams

• What is this condition?• What are the usual typical features?• What is the underlying predisposition of these patients?• What are the possible complications of this condition?• Describe the treatment• Any worries about certain treatment?

Scenario 5

This 21 yr old patient presented to his GP with a red painful swelling over his eye lid

• What is the condition?• What is the etio-pathology?• How would you treat this patient?• What other conditions cause similar eyelid swellings?

Meibomian Cyst Basal cell carcinoma

Cyst of Moll Cyst of Zeiss

                                                                           

Scenario 6

This 19 yr old female presented with a 2 day hx of pain, redness, intolerance to light, excessive watering and blurred vision

• What is your diagnosis?• What are the above examination findings?• What is the cause?• What complications could arise?• How would you treat this condition?

complications of uveitis

Hypopyon Secondary Cataract

Scanario 7

This 67 yr old patient presented with terrible pain in one eye and blurred vision for over 12 hrs. He now has a throbbing headache vomiting and his vision is getting worse

• Describe this picture• What is your diagnosis?• What are the types of this condition?• How will you manage this patient?

Scenario 8

Mrs Walker phones you whilst you are oncall at 6.30pm (just as you were about to go home). She says her 69 yr old hemiplegic husband has suddenly lost vision in his rt eye. Mr Walker also has a past Hx of Atrial Fibrillation

Fig 1 fig 2

• You visit Mr Walker at home and note that his fundus appears as in fig 1. Describe the 2 pictures and mention your primary diagnosis?

• Based on the history/ symptoms what would be your differential diagnosis?• How will you manage this patient?

C.R.V.O Vitreous Hemorrhage

Retinal detachment Amaurosis Fugax

Scanario 9

A 21 year old patient has come to see you today to get his eyes checked. He wants to start driving but is not sure if his vision is fine. On Snellen’s chart he can only read 3 letters in row 5 with the lt eye and 3 letters in row 4 with the rt eye.

• How will you record his V/A on a paper?

• Which is his better eye?

• How will you advice about the appropriateness of driving?

• Is there any other way you will test his vision for driving?

• He tells you he wants to apply for a job in a removal company. Is he allowed to drive a HGV?

• What is the law?

Scenario 10

A 65 yr old patient presents to you with a watery lt eye.

Fig 1 Fig 2

• What are the possible causes of excessive lacrimation (epiphora)? • What are the conditions in figures 1 and 2?• What causes can you think of leading to the above conditions?• What are the possible complications for the above?• How would you manage both conditions?

Scenario 11

This 28 yr old patient has a 5 day Hx of red and painful Lt eye. There is no discharge and his vision is normal

Fig 1 Fig 2

• What is the diagnosis?• What are the 2 types of this common condition shown in fig 1 & 2?• How will you manage this condition?• What is the severe form of this condition and its complications?

Spot the diagnosis

Sub Conjunctival Haemorrhage

Posterior Subcapsular Cataract

Age Related Macular Degeneration

Background Diabetic Retinopathy Pre-proliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy Advanced Diabetic Retinopathy

Compensated (I/ II) Hypertensive Retinopathy

Accelerated (iii/ iv) Hypertensive Retinopathy

BUT DON’T MISS THE MORE SERIOUS CONDITION. NEXT

Peri-orbital Cellulitis

Orbital Cellulitis

Pterygium

A woman presented to her GP with a Hx of floaters in her lt eye. Fundoscopy showed a blurred area at the centre of macula

Two more patients presented to the same GP that week needing a Fundal examination, and both displayed similar findings in their lt Eyes only.

IS THE OPHTHALMOSCOPE FAULTY? The GP referred himself to the ophthalmology department and was

diagnosed as having lt central serous chorioretinopathy. It took 4 months to resolve leaving residual retinal pigmentary change

• History is extremely important in making a diagnosis

• Always carry a Snellen’s chart with you

• NEVER FORGET TO STAIN A RED EYE

• Ophthalmic examination is not that difficult – It does get easier with practice IF YOU MAKE AN EFFORT

• All you need is a working knowledge in ophthalmology and some basic skills to figure out the problem. You are not expected to treat complicated eye problems

• Opticians/Optometrists are valuable resources available to GP’s. Make good use of them. It can prevent unnecessary referrals.

“DON’T TURN A BLIND EYE”