Jane Goodwin BSc MSc

Nurse Practitioner in Primary Care and Ophthalmic PwSI (practitioner with

specialist interest)

3.9.08 – GP Registrar

•Requests/concerns – what do you want ?•Examination – VA•Case studies•Examination - Ophthalmoscope•Case studies•Other presenting problems•Questions

Examination

• Visual Acuity• To asses distant

vision.• To determine if a

refractive or pathological disorder.

• Baseline• Medico/legal

requirement.

Equipment

• Pen Torch• Pin Hole• Snellen Chart• Ophthalmoscope• Fluorescien• Benoxinate• Tropicamide

Your Turn!

• In groups of 3 or 4

• 3 metres from chart

• Measure Va in each eye

• See instructions for further reference

Case Studies - One

The opticians letter states

‘this man has a cataract in the left eye and I have advised him to seek a specialist opinion’

His VA is 6/9 right and 6/12 left

1. What do you do as a GP?

2. Are there any options?

Ten weeks after uncomplicated cataract surgery a patients requests a further prescription of G. Maxidex. He missed his post operative review.

1. What are you going to do ?

Two

• Commonly used post op for 3-4 weeks QDS.

• Is normally stopped at post op visit.

• Request should be denied esp if eye white/asymptomatic.

• Early review at OPA

One year after cataract surgery, a patient complains of gradual deterioration in vision, in the operated eye.

1. What is the likely cause?

2. What do you do ?

Three

A 50 year old man notices a single black object in the field of his left eye. It moves on eye movements.

1. What is likely cause?

2. What will you do?

3. What features would concern you?

Four

Flashes and Floaters

Decreased Va?

Yes NO

Continued Transient

Typically 20 minutes

Duration

-Vitreous Haemorrhage -Ocular Migraine -PVD

-PVD with retinal detachment -(+/- retinal hole formation)

-Posterior Uveitis

Referral Guidelines Flashing lights and floaters

• Retinal holes and detachments – difficult to see with ophthalmoscope.

• Hx >6/52 Routine Referral

• Hx < 6/52 esp in under 55’s urgent OPD referral

• Hx recent onset with decreased VA – URGENT A/E

A 28 years old female presents with a smooth, round swelling in Left upper lid. It has been present for 2 months.

1. What is the likely diagnosis?

2. What do you do?

Five

• Meibomium cyst (Chalazion)

• Stye (abscess formation at root of

lash)

• Preseptal cellulitis

• Orbital cellulitis

A 20 year old women presents with bilateral red eyes that are gritty and burning. Discharge is evident on the lashes.

1. What is the likely diagnosis ?

2. What else could it be?

Six

• Vernal Conjunctivitis

• Chemosis - Conjunctival swelling

from allergy and excessive rubbing

• Blepharitis

• Oil secretion from

Meibomian Glands

Lid Hygiene

• 150ml Cooled boiled water

• 1 tea spoon Baby shampoo

• Mix and store in fridge up to 1/52

• Using cotton bud – clean top and bottom lashes (as if putting on eye liner)

• Daily for 2/52 then decrease to twice a week indefinitely

A 24 year old man presents with a painful left red eye that has been present for 5 days and has been getting worse every day. He is quite photophobic.

1. What do you do ?

2. What conditions do you consider ?

Seven

• Episcleritis

• Scleritis

• Dendritic Ulcer

• Anterior Uveitis (Iritis)

An 80 year old women complains of a very painful eye along with a feeling of nausea of 2 days duration. On examination the eye is red.

1. What condition do you want to exclude ?

2. How do you do this ?

Eight

• Acute Angle Closure

Glaucoma

• Digital Tonometry

Coffee Time !

A 75 year man complains of sudden loss of vision in one eye. Visual acuity is ‘hand movements’ only.

1. What are the likely causes?

2. What condition do you especially want to exclude ?

3. How do you do this ?

Nine

Central Retinal Artery Occlusion

• Milky white Retina with Cherry Red spot at the macula.

• Can present with sudden loss of vision or have transient vision loss a few days before.

Central Retinal Vein Occlusion

• Central vein which drains blood from the retina becomes blocked, causing a back flow of blood, hence the vessels leaking into the retina causing swelling.

• Ischemic causes of a blockage increases complications. Abnormal growth of blood vessels occur.

• Some can be treated with Laser

Optic Neuritis/Papilloedema

Examination of Fundus• Requires practice and confidence.• More accurate with dilated pupil.• Knowledge of A&P to interpret findings.• Limited view with direct ophthalmoscope.

RAPD (relative, afferent, pupillary, defect)

• RAPD is testing the nerve pathways to the brain. Inflammation, damage, or pressure on the nerves will cause a defect.

• Light shone into a healthy eye causes constriction in both eyes. Swing light to other healthy eye and same reaction will occur. Repeat 3 or 4 times.

• In a damaged eye – on swinging light to damaged eye neither pupil will constrict and damaged eye will start to dilate.

Ophthalmoscope Practice

• Find tops tips for using ophthalmoscope in hand out

• Get into small groups

• Practice !!!!!

Ten

A 60 year lady complains of recent onset of distorted and blurred vision especially when reading the newspaper.

1. What eye conditions do you suspect?

• Age related Macular degeneration

• Cataracts

• Diabetic Retinopathy

• Hypertension

ARMD – wet & dry

• Dry – 80% (however, 1 in 10 patients will develop wet)

• Cells under the macular break down & cause drusen (yellow deposits) under the retina.

• Signs – print is blurred, colours are dull, vision can be hazy and central vision is affected

WET

• Abnormal growth of blood vessels that leak blood and fluid.

• Causes scarring& permanent loss of central vision

• Signs – lines becomes wavy, door frames appear wonky.

• Onset is usually rapid.• Early diagnosis is critical if sight is to be

saved

Risk Factors

• Increases with age• Fhx / genetics• Gender – more common in females• Smoking• Obesity• Poor nutrition – enc colourful veg• CVD• Caucasian

Treatment

• Lucentis and Macugen – blocks abnormal vessel growth and leakage and targets proteins that are thought to cause ARMD.

• Intravitreal injections every 6 weeks 9 times a year.

• Post Rx – redness, specks in vision, Abx are commonly prescribed & monitor with amsler chart

Brief look at other conditions

Diabetic Retinopathy

• Known as Background or Non-proliferative

• Hard exudates – yellow flecks deep in the retina reflecting leakage of incompetent pre capillary retinal arterioles

• Haemorrhages – ‘red dots’ show mini blow outs of the diseased pre capillary arterioles

Proliferative

• This shows the tangling of blood vessels at the optic disc & nearby retina.

• The vessels are weak walled & break easily. They bleed into the retina & vitreous jelly & can cause retinal detachment & blindness.

• Treatment with argon laser is helpful

Glaucoma

• As a rule optic disc assessment is difficult as there is an infinite variety of normal optic discs.

• The main visible sign is thinning of the neuroretinal rim causing a larger central cup. As the disease progresses the rim is eroded until there is little or no rim left.

Normal disc

Cupped disc

Disc Oedema with Hypertension

• Disc oedema with splinter haemorrhages

• Caused from severe hypertension

Guess the condition

• Basal cell Carcinoma

• Papilloma• (removed for cosmetic

purposes)

• Cyst of Moll

• Cyst of Zeis

• Pinguecula

• Pterygium

• Entropian

• Ectropian

• Xanthelasma

• Milia

• Corneal Foreign Body

• Rust Ring

• Pigmented Lesion

• Conjunctival Melanoma

Paediatric ophthalmology

• Development of eyes reaches full maturity at 7 years of age.

• At birth an inborn reflex normally brings the image of an object onto the foveae of both eyes. Over time continual practice of this reflex is cemented into the ability to perceive depth.

• This can break down in two situations……

What are they?

1. If one eye has poor vision - eg Congenital Cataract High refractive error Ptosis – drooping eye lid Other pathology such as retinoblastoma

2. The other if one eye is squinting

Squint

• Brain ignores the image from poor eye and concentrates on the good eye.

• The poor eye turns in (convergent squint) and to avoid double vision the brain suppresses the image from this eye.

• If not corrected early, the eye does not develop hence the vision remains poor for life.

Final Question

Mother with 3 year old child presents saying she has noticed the Childs eye turning inwards.

O/E - you did not find any evidence of a squint

What do you do?

• Diagnostic drops to have in your surgery

– Benoxinate – anaesthetic – last for 20 mins great for FB removal.– Fluorescein – orange dye for ocular surface problems – Tropicamide – if need a clearer of view of fundus

• Glaucoma drops – check for bradycardia, and SOB. Most can be prescribed in packs of 3 – this is cheaper to prescribe and convenient for pt.

• Prostaglandin drops used in glaucoma eg Latanoprost cause eye lash growth, change in iris pigment and discolouration of skin under lower lid.

• Corticosteroid drops – never prescribe unless undergoing regular monitoring at local eye unit

• Artificial Tear drops / ointment – there are loads – start with hypromellose, then progress to gel tears and lacri-lube at night

• Antiviral ointment – I doubt you’ll prescribe without confirmation of herpetic infection• Antibiotic ointment / drops – next slide

What you need to know!

Chloramphenicol

• Ointment 1% - QDS– Abraisions– Dry eye syndrome– Soften FB or rust ring

– Easier to apply if tube warmed in hand/pocket.

– Size of grain of rice

• Drops 0.5% - QDS– Bacterial infection– No blurring of Va– To be stored in fridge

– DO not use in SOFT contact lens use.

– Asses if can instil drops

Fucithalmic

• Gel / drops 1%

• BD use as long acting 12hrs (no benefit using more frequently).

• Can sting for 10 secs on instillation.

• More convenient to use.

Chloramphenicol v Fusidic

Mini Review

Reference

• Griffiths P (2003) What type of eye drops should be given to a toddler with conjunctivitis? British Journal of Community Nursing, Vol 8 No 8 pg 364

Local Services to Epsom

• Surrey Association for Visual Impairment (SAVI)

• www.surreywebsight.org.uk Tel 0127664631

• Epsom and Ewell Club for the blind

• Tel 01372 723057

• Swail House – Ashley Rd - Housing for visually impaired -

Questions

The End

References• BNF 46 (2003) September

• Galbraith A et al (1999) Fundamentals of pharmacology, A text for nurses and health professionals. Addison Wesley Longman Ltd.

• Gregory R (1998) Eye and Brain, The Psychology of Seeing, 5 th Ed Oxford University Press, Oxford.

• Griffiths P (2003) What type of eye drops should be given to a toddler with conjunctivitis? British Journal of Community Nursing, Vol 8 No 8 pg 364.

• Kanski J (1999) Clinical Ophthalmology, Butterworth-Heinemann, Oxford.

• Maclean H (2002) The Eye in Primary Care , Butterworth-Heinemann, Oxford.

• Pavan-Langston D (1996) Manual of Ocular Diagnosis and Therapy, 4 th Ed, Little Brown and Company, Boston.

• Stein H (1992) Ophthalmic Terminology, 3rd Ed Mosy Year book, London.

• Stollery R (1997) Ophthalmic Nursing, 2nd Ed, Blackwell Science.