Eyes in General PracticeDr Bruce Davies

You are not alone!You are not alone!

A very popular topic How much time at medical school? What do the acuity numbers mean!

Special history

One or both? What disturbance of vision? Rate of onset? Any blind spots? Any associated symptoms e.g. floaters?

flashing lights? Exactly what is worrying the patient.

Contact lens use? Myopia? (increases risk of retinal detachment

10 fold) Any family history? (FH of glaucoma in a 1st

degree relative gives you a 1/10 lifetime risk, or squint)

Any history of diabetes, hypertension or connective tissue disease?

Examination

Snellan chart, 3m or 6m, simple text for near vision, PinholesFields, remember red and the quality of the red, simple 4

quadrant testing.Pupils: a bright torch and magnifying glassSquintMovementsOpthalmoscopy: Start at 10, red reflex?, green filter

enhances blood vessels, dilate prn, risk of acute closed angle glaucoma remote.

Clinical classification

Red eye Lids and tears Slow visual loss in the quiet eye Trauma Squints, new and congenital, rare

movement disorders …..(then a rare specialist rag bag)

Red eye

ConjunctivitisCommonest, an uncomfortable red eye.

Bacterial Discomfort. Purulent discharge. Spreads from

one eye to the other. Vision normal. Uniform engorgement Chloramphenicol first choice (?)

Conjunctivitis

Viral Often with an URTI. Gritty. Discomfort.

Watery discharge. May last many weeks. Photophobia. Small corneal opacities may

develop. Prolonged (often adenoviral) may need specialist therapy with steroids. Chloramphenicol to prevent 2nd infection.

ConjunctivitisChlamydia Mucopurulent, cornea inflamed, visual loss. Often

with STD. Permanent damage possible, topical and? systemic tetracyclines. Refer.

Infants Less than one month is notifiable disease - any

cause. May lead to scarring and permanent damage. Refer most.

Allergic Itching and discomfort. Chemosis and visual acuity

loss possible. Papillae and if big cobblestones. Cromoglycate may take days to start to work if bad.

Episcleritis / scleritis

Red sore eye. No discharge. Localised (viz. conjunctivitis=generalised) inflammation.

Episcleritis usually self limiting and idiopathic, no treatment needed.

Scleritis often with CT diseases, dangerous (perforation possible) Refer.

Corneal ulcers

Any infection, Abrasion, topical steroids, contact lens use. PAIN. - Except zoster May be general or localised inflammation. Must stain. Should evert upper lid to exclude a sub tarsal FB ?Hypopyon - pus in anterior chamber.

Refer most (except small abrasions - but refer if big or longer than 36 hours)

Remember recurrent abrasion syndrome.

Anterior uveitis

The uveal tract. So iritis, iridocyclitis and anterior uveitis are synonyms.

At risk: HLA-B27, CT diseases, past attacks, juvenile arthritis, sarcoid.

PAIN, then photophobia then visual loss. Ciliary flush. As it gets worse the pupil gets small and

reactions get sluggish, hypopyon, keratitis (back of cornea). These markers of it getting worse are bad news.

Refer all.

Acute closed angle glaucoma Often starts in the evening. Especially

in those over 50 years. Severe pain first. Impaired vision and

haloes around lights. May have history of past episodes relieved by going to sleep (the pupil constricts during sleep).

Refer even if attack spontaneously resolves.

Lids and tears

Chalazion = meibomnian cyst. In the lid. Warm

compresses and chloramphenicol. Persistent - incise.

Recurrent: ? DM, ? blepharitis, ? roseacea.

Can cause astigmatism from pressure.

Stye An infection of lash follicle. May be head

of pus - nick with needle. Or warm compresses and chloramphenicol.

Marginal cysts Non infected cysts from sweat or

sebaceous lid glands, if a problem can often be simply treated with a nick with a needle - small.

Blepharitis Common, underdiagnosed. Persistently sore eyes.

Gritty. Often with chalazions or styes. Inflamed lid margins, crusts, may have inflamed lids.

Associated with psoriasis, eczema and roseacea. Keep clean, antibiotic ointment[tetracycline], artificial

tears ? oral tetracyclines

Acute dacrocystitis Medial inflammation over lacrimal sac.

Refer, systemic therapy and topical urgently.

Orbital cellulitis Life threatening and blinding. Usually from

sinuses. Especially important in children who may become blind in hours.

Unilateral swollen lids which may not be red. The patient is ill, there is tenderness over the

sinuses, restricted eye movements. ADMIT

Ectropion Watery eye.. Laxity from age or nerve palsy.

Ointment and refer for LA operation to correct.

Entropion Common especially in the elderly. Scarring from the

lashes. Often results from blepharitis or chronic conjunctivitis Refer

Ingrowing lashes Damage to lids. May be removed but

will often need electrolysis or cryocautery to prevent recurrence.

Watering eyes Differential diagnosis.-

your homework!

Dry eyes Common, Remember to treat associated

blepharitis

Sudden visual loss

An easy list really as they all need specialist assessment!

Retinal detachment Floaters, photopsias, the shadow or curtain across the

sight.

Optic neuritis More women, pain on moving the eye, central scotoma

Posterior vitreous detachment Aged 50+, flashing lights, floaters

Vitreous haemorrhage Floaters, red haze may be present. Red reflex absent.

Disciform macular degeneration•Sudden disturbance of central vision.Vascular occlusions•Field loss. Diabetes, hypertensionMigraine•Youth, headache, zigzag lines, multicoloured lights.Cerebrovascular disease•Elderly, bilateral loss.

Slow visual loss

Refer to optician then ? refer. Cataracts Corneal opacities Macular problems Retinal problems

Trauma

Refer ! Unless really trivial

Squints

Refer Remember the orthoptist Can you do a cover test?