OPHTHALMOLOGY UPDATE
Ajay Bhatnagar
Consultant Ophthalmologist
Wolverhampton Eye Infirmary and Walsall Manor
Hospital
Overview• Acute eye problems in community setting
– Examination
– Differential diagnosis
– Management guidance
• Guidance / referral pathways for a few common
eye conditions– Watery eye / dry eye / Blepharitis
– Flashes and floaters
– AMD
– Diabetic retinopathy
Acute eye problems in community setting
The Red Eye
• Common causes
– Lids
• Blepharitis
– Ocular surface
• Tear film
• Conjunctiva
• Cornea
– Intraocular causes
• Anterior uveitis (iritis)
• Acute angle closure glaucoma
Acute eye problems in community setting
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
Acute eye problems in community setting
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
Acute eye problems in community setting
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
Acute eye problems in community setting
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
Acute eye problems in community setting
• 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
Acute eye problems in community setting
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)
Overview• Acute eye problems in community setting
– Examination
– Differential diagnosis
– Management guidance
• Guidance / referral pathways for a few common
eye conditions– Watery eye / dry eye / Blepharitis
– Flashes and floaters
– AMD
– Diabetic retinopathy
Watery Eye
• Excessive tear production
– Any irritation to ocular surface
(ingrowing eyelash, blepharitis, “cold wind”,
allergy)
– “Dry Eye”
• Problems with tear outflow
Watery Eye• Excessive tear production
– 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
Watery Eye
• 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
Watery Eye
• 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
Dry eyeMild to moderate • topical lubricants• Drops / Gel / Ointment• Preservative-free dropsModerate to severe• Punctal occlusion• Refer to eye clinic
BlepharitisMild to moderate • Lid hygeine• Topical lubricants
Moderate to severe• Oral doxycycline• Refer to eye clinic
Watery Eye
• 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
• Managing patient expectations
Overview• Acute eye problems in community setting
– Examination
– Differential diagnosis
– Management guidance
• Guidance / referral pathways for a few common
eye conditions– Watery eye / dry eye / Blepharitis
– Flashes and floaters
– AMD
– Diabetic retinopathy
Flashes and Floaters• Urgent referral to eye clinic
– Sudden onset, multiple floaters
– Recent onset, multiple flashes of light
– “Curtain” / visual field defect
• Non-urgent / No referral to eye clinic
– Long duration of floaters
– Occasional flash of light
Overview• Acute eye problems in community setting
– Examination
– Differential diagnosis
– Management guidance
• Guidance / referral pathways for a few common
eye conditions– Watery eye / dry eye / Blepharitis
– Flashes and floaters
– AMD
– Diabetic retinopathy
AMD• Dry AMD
– Gradual decline in vision
– Central vision impaired
– Long standing / slowly worsening distortion in
central vision
– Management
• Dietary supplements
• Supportive care (LVA, NGOs, CVI)
• Wet AMD
Wet (neovascular) AMD• Vision loss is more rapid
• Warning symptoms
– Recent onset distortion of central vision
– Recent onset blurred central vision
• Referral pathway
– Direct referral from Optom to fast track macula clinic (Fax
to WEI)
• Management
– Intravitreal injections
– Dietary supplements
– Supportive care (LVA, NGOs, CVI)
Overview• Acute eye problems in community setting
– Examination
– Differential diagnosis
– Management guidance
• Guidance / referral pathways for a few common
eye conditions– Watery eye / dry eye / Blepharitis
– Flashes and floaters
– AMD
– Diabetic retinopathy
Diabetic Retinopathy• All patients with DM – screened by DESP
• Patients with “referable retinopathy” are seen in hospital eye clinics
• Asymptomatic patients picked up DR at routine eye test:
– Are they being screened by DESP
– Are they already under care of HES? (WEI / WMH)
– Please write to the concerned Consultant
• Management
– Laser treatment – WMH / WEI
– Intravitreal injections for DMO (WEI only)
• How can primary care team help?
– Control of systemic risk factors – sugar, BP, cholesteral
– Fenofibrate?
In summary• Red, painful eye
• Differential diagnosis
• Which of these patients can be treated within primary
care and identifying those that need urgent referral?
• Management and referral pathways for
some common eye conditions
• Watery eye
• Flashes and floaters
• AMD
• DR