Jane Goodwin BSc MSc

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Jane Goodwin BSc MSc

• Nurse Practitioner in Primary Care and Ophthalmic
  PwSI (practitioner with specialist interest)

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3.9.08 GP Registrar

• Requests/concerns what do you want ?
• Examination VA
• Case studies
• Examination - Ophthalmoscope
• Case studies
• Other presenting problems
• Questions

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Examination

• Visual Acuity
• To asses distant vision.
• To determine if a refractive or pathological
  disorder.
• Baseline
• Medico/legal requirement.

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Equipment

• Pen Torch
• Pin Hole
• Snellen Chart
• Ophthalmoscope
• Fluorescien
• Benoxinate
• Tropicamide

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Your Turn!

• In groups of 3 or 4
• 3 metres from chart
• Measure Va in each eye
• See instructions for further reference

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Case Studies - One

• The opticians letter states
• this man has a cataract in the left eye and I
  have advised him to seek a specialist opinion
• His VA is 6/9 right and 6/12 left
• What do you do as a GP?
• Are there any options?

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Two

• Ten weeks after uncomplicated cataract
  surgery a patients requests a further
  prescription of G. Maxidex. He missed his post
  operative review.
• What are you going to do ?

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• Commonly used post op for 3-4 weeks QDS.
• Is normally stopped at post op visit.
• Request should be denied esp if eye
  white/asymptomatic.
• Early review at OPA

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Three

• One year after cataract surgery, a patient
  complains of gradual deterioration in vision, in
  the operated eye.
• What is the likely cause?
• What do you do ?

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Four

• A 50 year old man notices a single black object
  in the field of his left eye. It moves on eye
  movements.
• What is likely cause?
• What will you do?
• What features would concern you?

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• Flashes and Floaters
• Decreased Va?
• Yes NO
• Continued Transient
• Typically 20 minutes
• Duration
• -Vitreous Haemorrhage -Ocular
  Migraine -PVD
• -PVD with retinal detachment -(/-
  retinal hole formation)
• -Posterior Uveitis

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Referral Guidelines Flashing lights and
floaters

• Retinal holes and detachments difficult to see
  with ophthalmoscope.
• Hx gt6/52 Routine Referral
• Hx lt 6/52 esp in under 55s urgent OPD referral
• Hx recent onset with decreased VA URGENT A/E

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Five

• A 28 years old female presents with a smooth,
  round swelling in Left upper lid. It has been
  present for 2 months.
• What is the likely diagnosis?
• What do you do?

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• Stye (abscess formation at root of lash)

• Meibomium cyst (Chalazion)

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• Orbital cellulitis

• Preseptal cellulitis

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Six

• A 20 year old women presents with bilateral red
  eyes that are gritty and burning. Discharge is
  evident on the lashes.
• What is the likely diagnosis ?
• What else could it be?

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• Vernal Conjunctivitis

• Chemosis - Conjunctival swelling from allergy and
  excessive rubbing

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• Oil secretion from Meibomian Glands

• Blepharitis

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Lid Hygiene

• 150ml Cooled boiled water
• 1 tea spoon Baby shampoo
• Mix and store in fridge up to 1/52
• Using cotton bud clean top and bottom lashes
  (as if putting on eye liner)
• Daily for 2/52 then decrease to twice a week
  indefinitely

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Seven

• A 24 year old man presents with a painful left
  red eye that has been present for 5 days and has
  been getting worse every day. He is quite
  photophobic.
• What do you do ?
• What conditions do you consider ?

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• Episcleritis

• Scleritis

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• Dendritic Ulcer

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• Anterior Uveitis (Iritis)

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Eight

• An 80 year old women complains of a very painful
  eye along with a feeling of nausea of 2 days
  duration. On examination the eye is red.
• What condition do you want to exclude ?
• How do you do this ?

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• Acute Angle Closure Glaucoma

• Digital Tonometry

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Coffee Time !
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Nine

• A 75 year man complains of sudden loss of vision
  in one eye. Visual acuity is hand movements
  only.
• What are the likely causes?
• What condition do you especially want to exclude
  ?
• How do you do this ?

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Central Retinal Artery Occlusion

• Milky white Retina with Cherry Red spot at the
  macula.
• Can present with sudden loss of vision or have
  transient vision loss a few days before.

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Central Retinal Vein Occlusion

• Central vein which drains blood from the retina
  becomes blocked, causing a back flow of blood,
  hence the vessels leaking into the retina causing
  swelling.
• Ischemic causes of a blockage increases
  complications. Abnormal growth of blood vessels
  occur.
• Some can be treated with Laser

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Optic Neuritis/Papilloedema
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Examination of Fundus

• Requires practice and confidence.
• More accurate with dilated pupil.
• Knowledge of AP to interpret findings.
• Limited view with direct ophthalmoscope.

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RAPD (relative, afferent, pupillary, defect)

• RAPD is testing the nerve pathways to the brain.
  Inflammation, damage, or pressure on the nerves
  will cause a defect.
• Light shone into a healthy eye causes
  constriction in both eyes. Swing light to other
  healthy eye and same reaction will occur. Repeat
  3 or 4 times.
• In a damaged eye on swinging light to damaged
  eye neither pupil will constrict and damaged eye
  will start to dilate.

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Ophthalmoscope Practice

• Find tops tips for using ophthalmoscope in hand
  out
• Get into small groups
• Practice !!!!!

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Ten

• A 60 year lady complains of recent onset of
  distorted and blurred vision especially when
  reading the newspaper.
• What eye conditions do you suspect?

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• Age related Macular degeneration
• Cataracts
• Diabetic Retinopathy
• Hypertension

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ARMD wet dry

• Dry 80 (however, 1 in 10 patients will develop
  wet)
• Cells under the macular break down cause drusen
  (yellow deposits) under the retina.
• Signs print is blurred, colours are dull,
  vision can be hazy and central vision is affected

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WET

• Abnormal growth of blood vessels that leak blood
  and fluid.
• Causes scarring permanent loss of central vision
• Signs lines becomes wavy, door frames appear
  wonky.
• Onset is usually rapid.
• Early diagnosis is critical if sight is to be
  saved

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Risk Factors

• Increases with age
• Fhx / genetics
• Gender more common in females
• Smoking
• Obesity
• Poor nutrition enc colourful veg
• CVD
• Caucasian

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Treatment

• Lucentis and Macugen blocks abnormal vessel
  growth and leakage and targets proteins that are
  thought to cause ARMD.
• Intravitreal injections every 6 weeks 9 times a
  year.
• Post Rx redness, specks in vision, Abx are
  commonly prescribed monitor with amsler chart

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Brief look at other conditions
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Diabetic Retinopathy

• Known as Background or Non-proliferative
• Hard exudates yellow flecks deep in the retina
  reflecting leakage of incompetent pre capillary
  retinal arterioles
• Haemorrhages red dots show mini blow outs of
  the diseased pre capillary arterioles

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Proliferative

• This shows the tangling of blood vessels at the
  optic disc nearby retina.
• The vessels are weak walled break easily. They
  bleed into the retina vitreous jelly can
  cause retinal detachment blindness.
• Treatment with argon laser is helpful

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Glaucoma

• As a rule optic disc assessment is difficult as
  there is an infinite variety of normal optic
  discs.
• The main visible sign is thinning of the
  neuroretinal rim causing a larger central cup. As
  the disease progresses the rim is eroded until
  there is little or no rim left.

Cupped disc
Normal disc
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Disc Oedema with Hypertension

• Disc oedema with splinter haemorrhages
• Caused from severe hypertension

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Guess the condition
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• Basal cell Carcinoma

• Papilloma
• (removed for cosmetic purposes)

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• Cyst of Moll

• Cyst of Zeis

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• Pinguecula

• Pterygium

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• Entropian

• Ectropian

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• Xanthelasma

• Milia

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• Corneal Foreign Body

• Rust Ring

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• Pigmented Lesion

• Conjunctival Melanoma

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Paediatric ophthalmology

• Development of eyes reaches full maturity at 7
  years of age.
• At birth an inborn reflex normally brings the
  image of an object onto the foveae of both eyes.
  Over time continual practice of this reflex is
  cemented into the ability to perceive depth.
• This can break down in two situations

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What are they?

• If one eye has poor vision - eg
• Congenital Cataract
• High refractive error
• Ptosis drooping eye lid
• Other pathology such as retinoblastoma
• 2. The other if one eye is squinting

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Squint

• Brain ignores the image from poor eye and
  concentrates on the good eye.
• The poor eye turns in (convergent squint) and to
  avoid double vision the brain suppresses the
  image from this eye.
• If not corrected early, the eye does not develop
  hence the vision remains poor for life.

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Final Question

• Mother with 3 year old child presents saying she
  has noticed the Childs eye turning inwards.
• O/E - you did not find any evidence of a squint
• What do you do?

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What you need to know!

• Diagnostic drops to have in your surgery
• Benoxinate anaesthetic last for 20 mins great
  for FB removal.
• Fluorescein orange dye for ocular surface
  problems
• Tropicamide if need a clearer of view of fundus
• Glaucoma drops check for bradycardia, and SOB.
  Most can be prescribed in packs of 3 this is
  cheaper to prescribe and convenient for pt.
• Prostaglandin drops used in glaucoma eg
  Latanoprost cause eye lash growth, change in iris
  pigment and discolouration of skin under lower
  lid.
• Corticosteroid drops never prescribe unless
  undergoing regular monitoring at local eye unit
• Artificial Tear drops / ointment there are
  loads start with hypromellose, then progress to
  gel tears and lacri-lube at night
• Antiviral ointment I doubt youll prescribe
  without confirmation of herpetic infection
• Antibiotic ointment / drops next slide

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Chloramphenicol

• Ointment 1 - QDS
• Abraisions
• Dry eye syndrome
• Soften FB or rust ring
• Easier to apply if tube warmed in hand/pocket.
• Size of grain of rice

• Drops 0.5 - QDS
• Bacterial infection
• No blurring of Va
• To be stored in fridge
• DO not use in SOFT contact lens use.
• Asses if can instil drops

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Fucithalmic

• Gel / drops 1
• BD use as long acting 12hrs (no benefit using
  more frequently).
• Can sting for 10 secs on instillation.
• More convenient to use.

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Chloramphenicol v Fusidic

• Mini Review
• Reference
• Griffiths P (2003) What type of eye drops should
  be given to a toddler with conjunctivitis?
  British Journal of Community Nursing, Vol 8 No 8
  pg 364

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Local Services to Epsom

• Surrey Association for Visual Impairment (SAVI)
• www.surreywebsight.org.uk Tel [phone]
• Epsom and Ewell Club for the blind
• Tel [phone]
• Swail House Ashley Rd - Housing for visually
  impaired -

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Questions
The End
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References

• BNF 46 (2003) September
• Galbraith A et al (1999) Fundamentals of
  pharmacology, A text for nurses and health
  professionals. Addison Wesley Longman Ltd.
• Gregory R (1998) Eye and Brain, The Psychology of
  Seeing, 5th Ed Oxford University Press, Oxford.
• Griffiths P (2003) What type of eye drops should
  be given to a toddler with conjunctivitis?
  British Journal of Community Nursing, Vol 8 No 8
  pg 364.
• Kanski J (1999) Clinical Ophthalmology,
  Butterworth-Heinemann, Oxford.
• Maclean H (2002) The Eye in Primary Care ,
  Butterworth-Heinemann, Oxford.
• Pavan-Langston D (1996) Manual of Ocular
  Diagnosis and Therapy, 4th Ed, Little Brown and
  Company, Boston.
• Stein H (1992) Ophthalmic Terminology, 3rd Ed
  Mosy Year book, London.
• Stollery R (1997) Ophthalmic Nursing, 2nd Ed,
  Blackwell Science.