Eyes in General Practice

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Eyes in General Practice

• Dr Bruce Davies

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You are not alone!

• A very popular topic
• How much time at medical school?
• What do the acuity numbers mean!

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Special history

• One or both?
• What disturbance of vision?
• Rate of onset?
• Any blind spots?
• Any associated symptoms e.g. floaters? flashing
  lights?
• Exactly what is worrying the patient.

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• Contact lens use?
• Myopia? (increases risk of retinal detachment 10
  fold)
• Any family history? (FH of glaucoma in a 1st
  degree relative gives you a 1/10 lifetime risk,
  or squint)
• Any history of diabetes, hypertension or
  connective tissue disease?

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Examination

• Snellan chart, 3m or 6m, simple text for near
  vision,
• Pinholes
• Fields, remember red and the quality of the red,
  simple 4 quadrant testing.
• Pupils a bright torch and magnifying glass
• Squint
• Movements
• Opthalmoscopy Start at 10, red reflex?, green
  filter enhances blood vessels, dilate prn, risk
  of acute closed angle glaucoma remote.

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Clinical classification

• Red eye
• Lids and tears
• Slow visual loss in the quiet eye
• Trauma
• Squints, new and congenital, rare movement
  disorders
• ..(then a rare specialist rag bag)

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Red eye

• Conjunctivitis
• Commonest, an uncomfortable red eye.
• Bacterial
• Discomfort. Purulent discharge. Spreads from one
  eye to the other. Vision normal. Uniform
  engorgement Chloramphenicol first choice (?)

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Conjunctivitis

• Viral
• Often with an URTI. Gritty. Discomfort. Watery
  discharge. May last many weeks.
• Photophobia. Small corneal opacities may develop.
  Prolonged (often adenoviral) may need specialist
  therapy with steroids. Chloramphenicol to prevent
  2nd infection.

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Conjunctivitis

• Chlamydia
• Mucopurulent, cornea inflamed, visual loss. Often
  with STD. Permanent damage possible, topical and?
  systemic tetracyclines. Refer.
• Infants
• Less than one month is notifiable disease - any
  cause. May lead to scarring and permanent damage.
  Refer most.
• Allergic
• Itching and discomfort. Chemosis and visual
  acuity loss possible. Papillae and if big
  cobblestones. Cromoglycate may take days to start
  to work if bad.

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Episcleritis / scleritis

• Red sore eye. No discharge. Localised (viz.
  conjunctivitisgeneralised) inflammation.
• Episcleritis usually self limiting and
  idiopathic, no treatment needed.
• Scleritis often with CT diseases, dangerous
  (perforation possible) Refer.

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Corneal ulcers

• Any infection, Abrasion, topical steroids,
  contact lens use.
• PAIN. - Except zoster
• May be general or localised inflammation.
• Must stain. Should evert upper lid to exclude a
  sub tarsal FB
• ?Hypopyon - pus in anterior chamber.
• Refer most (except small abrasions - but refer if
  big or longer than 36 hours)
• Remember recurrent abrasion syndrome.

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Anterior uveitis

• The uveal tract. So iritis, iridocyclitis and
  anterior uveitis are synonyms.
• At risk HLA-B27, CT diseases, past attacks,
  juvenile arthritis, sarcoid.
• PAIN, then photophobia then visual loss.
• Ciliary flush. As it gets worse the pupil gets
  small and reactions get sluggish, hypopyon,
  keratitis (back of cornea). These markers of it
  getting worse are bad news.
• Refer all.

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Acute closed angle glaucoma

• Often starts in the evening. Especially in those
  over 50 years.
• Severe pain first. Impaired vision and haloes
  around lights. May have history of past episodes
  relieved by going to sleep (the pupil constricts
  during sleep).
• Refer even if attack spontaneously resolves.

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Lids and tears

• Chalazion
• meibomnian cyst. In the lid. Warm compresses
  and chloramphenicol. Persistent - incise.
• Recurrent ? DM, ? blepharitis, ? roseacea.
• Can cause astigmatism from pressure.

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• Stye
• An infection of lash follicle. May be head of pus
  - nick with needle. Or warm compresses and
  chloramphenicol.

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• Marginal cysts
• Non infected cysts from sweat or sebaceous lid
  glands, if a problem can often be simply treated
  with a nick with a needle - small.

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• Blepharitis
• Common, underdiagnosed. Persistently sore eyes.
  Gritty. Often with chalazions or styes. Inflamed
  lid margins, crusts, may have inflamed lids.
• Associated with psoriasis, eczema and roseacea.
• Keep clean, antibiotic ointmenttetracycline,
  artificial tears ? oral tetracyclines

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• Acute dacrocystitis
• Medial inflammation over lacrimal sac. Refer,
  systemic therapy and topical urgently.

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• Orbital cellulitis
• Life threatening and blinding. Usually from
  sinuses. Especially important in children who may
  become blind in hours.
• Unilateral swollen lids which may not be red.
• The patient is ill, there is tenderness over the
  sinuses, restricted eye movements. ADMIT

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• Ectropion
• Watery eye.. Laxity from age or nerve palsy.
  Ointment and refer for LA operation to correct.
• Entropion
• Common especially in the elderly. Scarring from
  the lashes.
• Often results from blepharitis or chronic
  conjunctivitis
• Refer

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• Ingrowing lashes
• Damage to lids. May be removed but will often
  need electrolysis or cryocautery to prevent
  recurrence.

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• Watering eyes
• Differential diagnosis.-
• your homework!
• Dry eyes
• Common,
• Remember to treat associated blepharitis

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Sudden visual loss

• An easy list really as they all need specialist
  assessment!

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• Retinal detachment
• Floaters, photopsias, the shadow or curtain
  across the sight.
• Optic neuritis
• More women, pain on moving the eye, central
  scotoma
• Posterior vitreous detachment
• Aged 50, flashing lights, floaters
• Vitreous haemorrhage
• Floaters, red haze may be present. Red reflex
  absent.

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• Disciform macular degeneration
• Sudden disturbance of central vision.
• Vascular occlusions
• Field loss. Diabetes, hypertension
• Migraine
• Youth, headache, zigzag lines, multicoloured
  lights.
• Cerebrovascular disease
• Elderly, bilateral loss.

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Slow visual loss

• Refer to optician then ? refer.
• Cataracts
• Corneal opacities
• Macular problems
• Retinal problems

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Trauma

• Refer !
• Unless really trivial

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Squints

• Refer
• Remember the orthoptist
• Can you do a cover test?