OPHTHALMOLOGY UPDATE Ajay Bhatnagar Consultant Ophthalmologist Wolverhampton Eye Infirmary and Walsall Manor Hospital

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


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)


• Anterior uveitis (iritis) – pain++, tenderness, photophobia

• Acute angle closure glaucoma – pain++, reduced vision


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


• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, hypopyon

• Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed dilated

pupil


The Red Eye

• Examination

– Lids


– Ocular surface





• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon


pupil


The Red Eye

• Examination

– Lids


– Ocular surface





• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, pupil, hypopyon


pupil


• Examination

– Lids


– Ocular surface





• Anterior uveitis (iritis) – circumcorneal congestion, cells, flare, hypopyon

• Acute angle closure glaucoma – CCC, corneal clouding, shallow AC, fixed

dilated pupil


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)


– Examination






– AMD


Watery Eye

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


– Dry eye , blepharitis

Watery Eye

• When to refer




– Suspected blocked tear duct – oculoplastic

surgery



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




– Suspected blocked tear duct – oculoplastic surgery



• Managing patient expectations


– Examination






– AMD


Flashes and Floaters

Posterior Vitreous Detachment

(PVD)

PVD Retinal D

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


– Examination






– AMD


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)


– Examination






– AMD


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

Questions / Comments

Thank You

Documents

OPHTHALMOLOGY UPDATE Ajay Bhatnagar Consultant Ophthalmologist Wolverhampton Eye Infirmary and Walsall Manor Hospital