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7/25/2019 Eye Elos Nes Algorithm Quiz 2.2.16
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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
https://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-pagehttps://www.eemec.med.ed.ac.uk/pages/resources/mw-ophthalmology-page7/25/2019 Eye Elos Nes Algorithm Quiz 2.2.16
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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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