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quiz 1 pic of the fundus

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Quiz 2

78 year old woman presents with painful

inflamed right eye

Whit next?

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Pic of the affected eye

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Quiz 3

28 year old man presents with acute onset

diplopia

Whit next?

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Pic of the patient

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Quiz 4

78 year old woman presents with a watery

right eye

Whit next?

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Pic of the patient

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Quiz 1 & algorithm

68 year old man presents with sudden

painless loss of vision right eye

Whit next?

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Visual Loss Algorithm

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Quiz 1

pupil reactions

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Pic of the fundus

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Quiz 2 & algorithm

78 year old woman presents with painful

inflamed right eye

Whit next?

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Red Eye Algorithm

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Pic of the affected eye

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Quiz 3 & algorithm

28 year old man presents with acute onset

diplopia

Whit next?

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Diplopia Algorithm

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Pic of the patient

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Quiz 4 & algorithm

78 year old woman presents with a watery

right eye

Whit next?

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Pic of the patient

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Mark Wright Consultant

Ophthalmologist Lothian Health

and Edinburgh University

Algorithm based clinical teachingdoes it work?

elos/nes 2.2.16

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Role & training of optometrists

Optometrists are extending their role both diagnostically

and therapeutically & slowly taking over the role of GPs

in managing primary care ophthalmology

Greater clinical expertise required by the 2006 GOS

contract however HES reluctant to devote time to

optometry/orthoptic teaching because of service

pressures

Could algorithm based clinical teaching help?

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Is there a place for diagnostic

algorithms in ophthalmology? A partial solution to the ever increasing pressure on

hospital eye services (HES) is to improve the partnershipbetween community optometrists and HES

The following slides illustrate the results of threeprospective clinical trials which document the accuracy ofthe Edinburgh Eye Algorithms (5) when used byinexperienced clinicians in the three most commonlyencountered clinical scenarios; red eye (s), visual lossand diplopia

They highlight the existing diagnostic deficiencies withinour referral groups and demonstrate the significantimprovement in these deficiencies when our simplediagnostic algorithms are applied to patients presenting

with red eye (s), visual loss and diplopia

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Edinburgh Red Eye Algorithm

Baseline diagnostic accuracy for non ophthalmologists

for patients presenting with AACG was 21% (GPs)64%(A&E)1and for iritis (GPs) 44%2

When equally inexperienced observers (GP 35%, A&Enurse practitioners 23%, opticians 18% etc) assessedpatients presenting with red eye (s) using the EdinburghRed Eye Diagnostic Algorithm the diagnostic accuracy for

AACG rose to 100% (4/4 cases) and for iritis rose to 82%(9/11 cases)

For all causes of red eye (s) the overall diagnostic

accuracy was 72% (28/39)31 Siriwardena D, Arora AK, Fraser SG, McClelland HK, Claoue C. Misdiagnosis of acute angle closure glaucoma. Age

Ageing. 1996;25(6):421-3.

2 Sheldrick JH, Vernon SA, Wilson A. Study of diagnostic accord between general practitioners and an ophthalmologist.BMJ.1992; 304:1096-1098.

3 Accuracy of the Edinburgh Red Eye Algorithm. Eye2015; 29: 619-624.

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Edinburgh Visual Loss Diagnostic Algorithm

The overall pre-algorithm diagnostic accuracy of referrers assessingpatients presenting with visual loss was 51% (30/59). Individual accuracywas; optoms 67%, A&E doctors 33%, GPs 13%, other hospital specialties0%

The diagnostic accuracy improved to 84% (57/68) when inexperiencedobservers (4thyear medical student 45% [31/68], junior ophthalmologytrainee 37% opticians 18%) assessed the same cohort of patients using the

Edinburgh Visual Loss Diagnostic Algorithm

4

The algorithm correctly diagnosed: retina in 71% of cases (5/7), macula in86% (25/29), peripheral retina in 100% (2/2), optic nerve in 71% (5/7),media opacity in 89% (16/18), post chiasmal in 100% (4/4) and refractiveerror in 0% (0/1)

Accuracy of diagnosis was similar for each algorithm user; medical student81%, inexperienced ophthalmology trainee 84% and optometrist 92%.

4 The Accuracy of the Edinburgh Visual Loss Diagnostic Algorithm. Accepted for publication in EyeJuly 2015

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Edinburgh Diplopia Diagnostic Algorithm

The overall pre-algorithm diagnostic accuracy of referrers assessing

patients presenting with diplopia was 24% (10/41). Individualaccuracy was; A&E & other hospital doctors 20%, GPs 44%, optoms36%. In 54% of the cases (22/41) the referrer did not make anattempt to diagnose the cause of the diplopia.

The diagnostic accuracy improved to 82% (37/45) When

inexperienced observers (FY2 & 5th

year medical student) assessedthe same cohort of patients using the Edinburgh Diplopia DiagnosticAlgorithm5

The algorithm correctly diagnosed: CN III palsy in 6/6, CN IV palsyin 7/8, cranial nerve (CN) VI palsy in 12/12, internuclear

ophthalmoplegia in 2/2, restrictive myopathy in 4/4, media opacity in1/1 and blurred vision in 3/3. The 7 incorrect diagnoses included;myasthenia gravis, Miller Fisher Syndrome,post head injurydiplopia and two cases of dual CN (CN 111 & IV and 111 & VI)palsies.

5 The Accuracy of the Edinburgh Diplopia Diagnostic Algorithm; accepted eye January 2016

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Edinburgh Eye Algorithms

These are the first diagnostic eye algorithms to besubjected to scientific analysis and lead to significantimprovements in the diagnostic accuracy ofinexperienced clinicians in the three most commonlyencountered ophthalmic scenarios

We have offered these algorithms to all interestedparties; RCOph, College of Optometrists, RCEMedicine,RCGP etc. with an app under development

A number of open access learning tools includingdownloadable copies of the 5 diagnostic algorithms andnarrated lectures accompanying the algorithms areavailable athttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-page

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Approach to patients presenting

with red eye(s) KEY POINTS IN THE OCULAR EXAMINATION AND

DECISION MAKING POINTS IN THE RED EYE ALGORITHM

Unilateral vs bilateral redness

Always look at the lids before the eye(s)! Presence of fluorescein staining esp. if the cornea is

clear

Corneal appearance; clear or hazy; focally ordiffusely hazy

Difference in the pupil size (anisocoria)

Presence of photophobia

(Pattern of redness; diffuse or sectorial)

Direct ophthalmoscope gives an illuminated

magnified view

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R d E Al ith

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Red Eye Algorithm

d il t l bil t l?

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redness unilateral or bilateral?

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Redness unilateral or bilateral?

bilateral red eyes

d i t l t ?

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predominant ocular symptom?

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predominant symptom itch

allergic conjunctivitiswhich is;

often associated with atopy; asthma,

eczema and hay fever can be associated with a stringy more than

a purulent discharge

treatment is allergen avoidance if possibleand optanolol drops if not

d i t l t ?

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predominant ocular symptom?

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di h t?

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discharge present?

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predominant ocular symptom

gritty and burning with no discharge

dry eyes

eyes are minimally red

almost always in older patients

Unilateral only in the presence of incomplete

closure i.e. facial nerve palsy

Treatment is long term ocular lubricants;viscotears during the day and lacrilube at night

redness unilateral or bilateral?

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redness unilateral or bilateral?

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Redness unilateral or bilateral?

unilateral red eye

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Red eye; signs

The second thing to

check in a patient with

a red eye(s) is.

R d i l k t th

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Red eye; signs-look at the

lids! Lid margin lesions Entropion/trichiasis

Lagophthalmos

lashes touching the eye?

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lashes touching the eye?

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lashes touching the eye

entropion or trichiasis

normal eyelid closure?

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normal eyelid closure?

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incomplete eyelid closure

facial nerve palsy

Red eye(s); the most important

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Red eye(s); the most importantsingle thing to do to a red eye(s)

is1. Check the vision

2. Digitally estimate the intraocular

pressure

3. Instil fluorescein dye

4. Evert the lid looking for a sub tarsal F.B.

5. Check the pupil reactions

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cornea stains with fluorescein

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cornea stains with fluorescein

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cornea stains but is clear

epithelial keratitis; infectious

(h.s.v.), trauma, chemical etc

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cornea stains and is hazy

stromal keratitis; abscess

no corneal staining with fluorescein

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no corneal staining with fluorescein

P il l h d id

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Pupil larger on the red eye side

acute angle closure glaucoma

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h t h bi t

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photophobia present

iritis

photophobia absent

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photophobia absent

i t

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eye pain present

scleritisoften associated with

ocular tenderness

i b t

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eye pain absent

episcleritisnot usually associated

with ocular tenderness

Approach to patients

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Approach to patients

presenting with visual loss

Key step is to map out the patients visual field defectusing confrontational visual fields which will allow you tolocate which part of the visual pathways are affected

Measure the visual acuity and if reduced again with thepinhole

The only specialised test required is the swingingflashlight test to determine whether an RAPD is present

Lastly, use the history and PMH/age etc to best guess

the likely cause and then confirm using theophthalmoscope

Visual Loss Algorithm

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Visual Loss Algorithm

4 practical skills

Confrontational visual field

Visual acuity

Pupil reactions (rapd)

Fundoscopy

Visual loss

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Visual loss

algorithm

Visual loss confrontational V F

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Visual loss-confrontational V.F.

testing

Visual loss-swinging flashlight

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Visual loss swinging flashlight

test (RAPD)

Run the video clip of the RAPD

Visual loss

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Visual loss

algorithm

Approach to patients presenting with

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Approach to patients presenting with

diplopia; clarify the history

Clarify the patient means they see two separate

images i.e. true diplopia and not one blurred image

Secondly ask if when the patient covers each eye

separately the double image goes i.e is the diplopia

monocular or truly binocular

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Double vision

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Double vision

(diplopia)

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Quiz 1

28 year old man presents with acute onset

diplopia

What next?

Diplopia Algorithm

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Diplopia Algorithm

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Pic of the patient

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Q i 2

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Quiz 2

Show pupil reactions (RAPD video)

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Q i 3

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Quiz 3

78 year old woman presents with painfulinflamed right eye

What next?

Pic of the affected eye

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Pic of the affected eye

Q i 4

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Quiz 4

8 year old boy presents with a differencenoted in his pupil sizes

What next?

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