Idiot’s guide to eye problems

1. Idiot’s guide to eye problems Cass Adamson January 2011

2. What do GPs need to know? • Many conditions • Wealth of info • GP books short chapters • Serious consequences if wrong

3. Take home message: • If in doubt – REFER!!!

4. Session plan: • Presentation on assessing and managing common or serious eye problems • Videos on eye examinations (optional) • Practical session for practising fundoscopy and other eye examinations • CSA practise

5. Eye assessment • External examination of eyes and face • Visual acuity • Visual fields • Pupils + swinging torch test • Fundoscopy • Eye movements

6. “There’s something in my eye” • Joan Peters 65 • Controlled hypertension • 5/7 ago sudden appearance of ‘tadpole’ in L eye with some flashing lights. • No trauma • Vision NAD

7. BP 148/79 Eyes appear normal PEARL Eye movements NAD Fields NAD VA (with glasses) R – 6/5 L – 6/6 Fundoscopy:

8. What do you do? • Reassure her • Advise optician r/v • Ask about foreign travel and explain that the ‘tadpole’ could be a worm • Refer routinely • Refer urgently • Refer immediately

9. Posterior vitreous detachment - normal examination - Floater black ‘cobweb’ or ‘curtain’ • But new flashes and floaters are retinal detachment or retinal tears until proven otherwise. → refer urgently

10. Retinal detachment • Rhegmatogenous or • traction. • Flashes, floaters and • field loss – curtain from • periphery • Blurred central vision

11. Flashes and floaters Floaters large and red or black Tearing or bleeding Floating blobs or severe visual loss Retinal tear Vitreous haemorrhage

12. “It’s double vision, Doc” • Hanif Khan 47 • Occasional headaches • Last night sudden onset diplopia and a headache which is worsening. • Taken some ibuprofen, partial relief

13. L eye looking down and outwards Unable to look up, down or medially Partial ptosis L pupil slightly dilated and less reactive to light

14. What do you do? • Inform him it is a CN III palsy and to come back if his symptoms worsen • Prescribe analgesia for headache • Ask optician to examine fundi then r/v patient • Refer routinely • Refer urgently • Refer immediately

15. New sudden onset diplopia adult has a life threatening cause eg aneurysm until proven otherwise → immediate referral • Gradual onset diplopia in adult can be tumour. • Can see transient or persisting diplopia with temporal arteritis

16. Intoxication Head injury CVA Orbital floor # Guillain-Barre Myasthenia gravis Early cataract CN III, IV, VI palsies Other signs to look for: Enlarged pupil, ↓ response light – CN III palsy Ptosis – CN III palsy or MG Lid retraction – thyroid eye disease Red eye – thyroid eye disease or orbital inflammation Ocular torticollis – CN IV palsy Causes of diplopia:

17. Serious eye/brain disease likely if symptoms: Unexplained eye pain Photophobia Distortion vision Flashes of light New floaters Loss part visual field Sx temporal arteritis Serious eye/brain disease likely if signs: Red eye Visual field defect RAPD Abnormal cornea, iris or pupil Loss red reflex Optic disc swelling or pallor Blurred vision:

18. “ I can’t see in my left eye!” • Hannah Cook 76 • Type 2 diabetes and hypertension • This morning sudden reduced vision L eye • Mildly painful • DH: bendroflumethiazide, metformin, simvastatin and aspirin

19. BP 156/66 Last HbA1c 7.9% VA (with glasses) R – 6/9 L – 6/18 Eye movements NAD Possible RAPD Fundoscopy:

20. What is it?

21. What do you do? • Review her medications and add in a further agent for BP and DM • Make sure she sees her optician soon as her glasses are clearly inadequate • Refer routinely • Refer urgently • Refer immediately

22. Central retinal vein occlusion: • Widespread retinal haemorrhage • Tortuous dilated veins • Macular oedema • Optic disc swelling • +/- cotton wool spots. • Proliferative Diabetic Retinopathy: • Cotton wool spots • Hard exudates • Dot and flame haemorrhages

23. Branch retinal vein occlusion: Appearance similar to CRVO Sx: sudden blurring or field defect Central retinal artery occlusion: Sudden painless loss all vision ↓↓↓ VA (light only), RAPD Pale retina, cherry red macula

24. Transient visual loss: BOTH ONE

25. Sudden or rapid visual loss: ONE BOTH NO YES

26. Gradual visual loss: NO YES

27. “My eyes keep going funny” • Jemima Duck 26 • Had headache past 3/52. 4/7 when bending forwards nausea and transient visual loss • BMI 29.6 • Takes COCP • No PMH

28. ?RAPD (subtle) Eye movements NAD VA L - 6/9 R – 6/12 Fields - ?central scotoma Fundoscopy (bilateral):

29. What do you do? • Refer for routine CT/MRI head • Refer for urgent CT/MRI head • Call 999 • Admit medical team • Refer to ophthalmology routinely • Refer to ophthalmology urgently

30. Papilloedema: • Unilateral – disease within eye • Bilateral - ↑ICP

31. “My eye is droopy” • Bob Smith 54 year old smoker. • 5/7 drooping L eyelid, worsening • Otherwise asymptomatic

32. Possibly some weight loss Longstanding mild dry cough Probable Pancoast’s Syndrome Other causes: Head or neck trauma Brainstem stroke Dissecting internal carotid aneurysm

33. Approach to ptosis: • Bilateral: age related or MG • Mild: Horner’s syndrome • Double vision or limited eye movements: MG or CN III palsy • Pupil small: Horner’s • Pupil large: CN III palsy • Fatigability: MG →refer

34. “My eye looks odd” • Sarah Brown 19yr. • Her mother noticed her R eye looked ‘odd’ this morning. • Recent bad cold. • No PMH • Takes COCP

35. Adie’s pupil • Unilateral dilated pupil • Poor or no response light.

36. Unequal pupils: YES NO YES YES NO NO

37. More words of wisdom: • Not all flashing lights with headache are migraine • Blurred vision or headache needs field test • Field loss always needs assessment • Sudden onset visual distortion – urgent ref • Consider temporal arteritis every pt >50 with headache or visual change

38. Red eye with decreased vision, pain or photophobia needs same day referral. • Any child with a turned eye has sight/life threatening condition unless disproved • New onset flashes and floaters are retinal detachment until proven otherwise

39. References: 1. Pulse Plus – Ophthalmology 2. Pulse – Picture quiz: Acute Referrals to Ophthalmology 3. Practical Ophthalmology – A Survival Guide for Doctors and Optometrists (2005). A. Pane and P. Simcock 4. Symptom Sorter 4th ed (2010). K. Hopcroft and V. Forte 5. The 10-Minute Clinical Assessment (2010). K. Schroeder 6. Google images!

40. Funsdoscopy: • http://www.heine.com/eng/INFO-CENTER/INFORMATION-LITERATURE/Filme-und-Neuheiten/Direct-Ophthalmoscopie