Ophthalmology in Primary Care

Matt EdmundsClinical Lecturer / Specialty RegistrarAcademic Unit of OphthalmologyUniversity of Birmingham

What I have been asked to address (1)

What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?

Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?

What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow morning/clinic? How should we access these/ advice OOH?    

What I have been asked to address (2)

The red eye   

What to do about dry eyes/ watering eyes/ blepharitis  

What to do about floaters and/ or flashes   What mistakes do we make in our history-

taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?   

Question 1:

What is an acceptable GP eye examination: pupils/ APD/ VA/ fluorescein/dilation or not - when is it acceptable to ask an optician to help before referral?

What mistakes do we make in our history-taking etc. that we should be thinking of/ asking to avoid unnecessary referrals – i.e. we should be able to manage?   

Ophthalmology in primary care Broad generalisation…….

Most patients will present with ‘red eye’ Significant proportion of red eye can be

managed in primary care▪ Whereas most ‘non-red eye’ pathology is likely to

require secondary care input Limitations

Not much training in eyes▪ Year 4 MBChB at UoB: 5 days ophthalmology▪ Few GP VTS posts in ophthalmology across Midlands

Lack of equipment Pressurised for time

History

Acute or gradual onset? One or both eyes? Is vision affected? Discharge?

Purulent? Watery?

Pain? Sensitivity to light? Contact lens wearer? Previous episodes? Industrial injury? Associated systemic symptoms?

What we would hope for….

Visual acuity (and idea of any recent changes) Pupil reactions Eye movements Gross observations

Lid swelling and discharge / lash crusting Distribution of any redness / obvious eye lesions Corneal staining with fluorescein / FB Comment on anterior chamber / cornea▪ TIP: Ophthalmoscope on +20D

Optic disc / fundus Not easy with ophthalmoscope Please, at least try

Visual acuity testing

Can use book eg BNF/BMJ if snellen chart not available on wards

Snellen charts needed in practice

How to tell a person’s refraction

Hypermetrope (convex)

Myope (concave)

Almost emmetropic

Visual acuity testing

If unable to read top line on Snellen chart:

Visual acuity testing

If unable to read top line on Snellen chart:

Count fingers? (CF)

Visual acuity testing

If unable to read top line on Snellen chart:

Count fingers? (CF)

Hand movements? (HM)

Visual acuity testing

If unable to read top line on Snellen chart:

Count fingers? (CF)

Hand movements? (HM)

Perceive light? (PL)

Visual acuity testing

If unable to read top line on Snellen chart:

Count fingers? (CF)

Hand movements? (HM)

Perceive light? (PL)

No light perception (NLP)

Apologies!

Conjunctiva

Limbus IrisCornea Lower

punctum

Upperpunctum

Caruncle

Over the phone

Temporal Nasal

Superior

Inferior

12

6

9 3

Question 2:

Any tips/ tricks other than practice for better ophthalmoscopy/ fundoscopy?

Dark room Dim ophthalmoscope light Smaller pupil setting Get patient to look into distance ?Pharmacologically dilate pupilsMainly: have low expectations!

Question 3:

What possible emergency/ urgent eye conditions do you think need: Immediate referral/today/tomorrow

morning/clinic? How should we access these/ advice OOH?

Key things to remember

There may be disparity in sense of urgency

You may get a different response to a referral at different times of the day – appropriate

Please don’t ‘opt out’ of ophthalmology

Please always send a brief referral letter

Guidelines for Referrals Same day

Acute glaucoma Temporal arteritis (with definite ophthalmic symptoms) Painful eye after cataract surgery Painful or red eye after corneal graft Painful or red eye in contact lens wearer Orbital cellulitis Suspected corneal infections

Could wait until next day Uveitis Zoster with eye involvement Scleritis

If not resolving as expected Conjunctivitis Episcleritis

Via out-patient clinic Blepharitis / Dry eye / Chronic grittiness or soreness Entropion Ectropion

I will see overnight…

GCA with eye involvement Temporal pain / jaw claudication / night sweats / weight

loss / transient visual obscurations / visual disturbance CRAO within past 24 hours

Sudden and persistent unilateral painless loss of vision Orbital cellulitis Significant chemical injury Suspected penetrating eye injury / significant

trauma Retrobulbar haemorrhage

Acute glaucoma Suspected endophthalmitis

Painful red eye / reduced vision / recent intra-ocular intervention

Can wait until tomorrow morning…

Suspected retinal tear / detachment Suspected vitreous haemorrhage Suspected optic neuritis (unless GCA) New onset diplopia

Unless 3rd nerve palsy / complex CN palsy

Most trauma Most red eye pathology

BMEC Eye Casualty

Open for walk-in patients 365 days / year No referral necessary

Accept all patients 9am – 7pm Mon-Sat / 9am-6pm Sun and Bank Holidays

Urgent care clinic available via triage nurse Also have acute referral clinics at RHH / SGH

Limited number of clinic slots Accept direct GP referrals

No emergency eye clinic at QEH

OOH

On-call registrar via telephone overnight

Discuss emergency patients

Review patients on eye ward if necessary (Sheldon Block, City Hospital, Dudley Road)

Senior SpR (4th on-call) will review patients in peripheral units if necessary

If in doubt

Contact triage nurse at BMEC Call on-call SpR (2nd or 4th on-call) at

BMEC Send to BMEC eye casualty

With a letter If patient will arrive before closing time

(7pm)

Question 4:

The red eye!

What to do about dry eyes/ watering eyes/ blepharitis 

Red Eyes

Up to 80% of eye casualties present with a red eye

Causes of a red eye can be roughly divided into two groups Pain +/- blurring of vision No pain and normal vision

Common pathology is common! Most red eyes are due to conjunctivitis /

blepharitis / dry eye If you can confidently exclude ‘serious’

pathology Oc. Chloramphenicol 1.0% QDS Warm compresses Lid hygiene Lubricants PRN▪ Celluvisc / Optive / Systane / Hyloforte / Xailin

Olapatidine BD (Opatanol) for allergic disease Discuss / refer if not improving / resolving

Pain +/- blurred vision

Important differential diagnoses include: Acute glaucoma Corneal infections Anterior uveitis

(iritis) Scleritis

No pain Differential

diagnoses include: Conjunctivitis Episcleritis Subconjunctival

haemorrhage

Red Eyes

Causes

Eyelids Conjunctivitis

Bacterial Viral Chlamydial Allergic

Keratitis Bacterial (Marginal) Viral

(Episcleritis) / scleritis Acute anterior uveitis

(iritis) Angle closure glaucoma Orbit

Orbital cellulitis Trauma

Subconjunctival haemorrhage

Corneal abrasion Corneal FB Chemical burn

Blepharitis

Chronic inflammation of

the eyelid margins

Causes

Usually Staph aureus or

epidermidis

Associated with skin disease •Acne rosacea•Seborrhoeic dermatitis

Symptoms

Sore

Gritty

Occasionally red eyes

Examination

Hyperaemic lid

margins

Crusts on lashes

Blocked meibomian

gland orifices

Meibomian cysts

Complications

Conjunctivitis

Marginal keratitis

Meibomian cysts

Blepharitis – Treatment Lid hygiene Warm compresses

Gentle expression of lipids with a cotton tipped applicator

Gentle lid cleaning with a solution of sodium bicarbonate

Antibiotic ointment Lubricants Omega-3 Low dose tetracyclines

Antibiotics Lipid soluble Protease inhibitors

StyeInfected hair follicle

ChalazionBlocked meibomian gland

Entropion

Ectropion

In-turning of the lower lid

Out-turning of the lower lid

Herpes zoster ophthalmicusShingles

Conjunctivitis

Bacterial

Viral

Chlamydial

Allergic

Cicatrising

Bacterial conjunctivitis

Causes

Usually staphylococcus, streptococcus or

haemophilus species

Symptoms

Slight discomfort

Red, sticky eye(s)

Visual acuity is not affected although

slight blurring due to purulent exudation, which clears when

discharge is blinked away

Examination

Generalised conjunctival injection

with purulent discharge

lashes may stick together

Bacterial conjunctivitis

Causes

Usually staphylococcus, streptococcus or

haemophilus species

Symptoms

Slight discomfort

Red, sticky eye(s)

Visual acuity is not affected although

slight blurring due to purulent exudation, which clears when

discharge is blinked away

Examination

Generalised conjunctival injection

with purulent discharge

lashes may stick together

Bacterial conjunctivitis

Complications

Usually nil

Treatment

frequent antibiotic drops - instil hourly for 24 hours

then qid for a week

general hygiene by not sharing towels

etc

Viral conjunctivitis

Causes

Usually adenovirus (self-limiting, but can

also affect cornea -

keratoconjunctivitis)

Symptoms

Red, watery eye(s)

Gritty, uncomfortable

feeling

Viral conjunctivitis examination

Vision unaffected unless the cornea is involved

Generalised conjunctival

injection with watery discharge

Follicles (lymphoid

aggregates) in the tarsal conjunctiva

Petechial conjunctival haemorrhag

es

Enlarged pre-

auricular lymph node

Associated URTI

Viral conjunctivitis

Complications

Highly contagious• Risk of epidemics• Nosocomial

transfer

May last several weeks

Small corneal opacities leading to

photophobia and reduced

vision

Treatment

Nil

Antibiotic drops to prevent secondary bacterial infection

General hygiene by not sharing towels

etc

Chlamydial conjunctivitis

“Unilateral red eye in a young male”

Red, watery eye(s)

Vision unaffected

Gritty, foreign body

sensationChronic

Follicular reaction

Usually young adults

Sexually acquired

Requires systemic

antibiotics

Allergic conjunctivitis

Acute onset Red, itchy eye(s)

Chemosis (conjunctival

oedema)Vision unaffected

Type 1 hypersensitivity reaction•Seasonal•Perennial

Often settles spontaneously

Oral antihistamines

Sodium cromoglycate /

Olapatidine

Keratitis

Bacterial

ViralAutoimmune

Fungal

Bacterial keratitisBacterial infection of the cornea

An ophthalmic emergency

Causes

Large range of gram

positive or negative

organisms

Predisposing factors include

Corneal abrasion

Contact lenses

(usually soft

extended wear)

Topical steroids

Corneal anaesthesia

(e.g. previous herpes zoster ophthalmicus

)

Clinical Features

Symptoms

Red, sticky eye

Pain

Reduced vision

Photophobia

Examination

Conjunctival injection with

purulent discharge

Corneal abscess

(yellow/white area on cornea)

May be activity (cells)

in anterior chamber

Clinical Features

Clinical Features

Complications

Severe sight-threatening intraocular infection

(endophthalmitis)

Corneal perforation

Loss of eye

Treatment

Admit•Scrape cornea•Gram stain•Culture and sensitivities

Bacterial keratitis treatment

Sterilisation phase• Hourly antibiotics (usually

monotherapy with a fluroquinolone) day and night for 2 days

• Hourly antibiotics by day for three days

• Cycloplegics• Intraocular hypotensives• Sub-conjunctival injections to be

AVOIDED

Healing phase• Healing retarded in persistent

inflammation• Judicious use of topical

glucocorticoids• Treat ocular surface disease (dye eye,

entropions, blepharitis)

Causes

Herpes simplex type I

(commonest)

Symptoms

Reduced vision - frequently

Unilateral red eye

Pain

Photophobia

Examination

Conjunctival injection

Classical branching dendritic

(epithelial) ulcer staining with fluorescein

Reduced corneal sensation

Complications

Corneal scarring

May affect deeper corneal

layers e.g. stroma (disciform

keratitis)

Corneal perforation

Viral keratitisViral infection of the cornea

Herpes simplex keratitis

Viral keratitis

Complications

DO NOT USE

STEROIDS

Treatment

• Secondary bacterial infection

• Ulcer may recur

• Geographical ulceration

• Antiviral ointment (e.g. aciclovir) tapering over a few weeks

• Dilate pupil

Scleritis

Idiopathic

Infective

Systemic

disease

Scleritis

Anterior scleritis is sub-divided into • Diffuse • Nodular • Necrotising

Anterior scleritis is commonest but posterior

involvement also occurs Inflammation of the

outer (white) coat of the eye and can be a severe

destructive, sight-threatening disease

Scleritis

Causes

Majority idiopathic

40% associated with a connective tissue or vasculitic

disease, commonest being

rheumatoid arthritis

Infections• Varicella Zoster• Acanthamoeba• Bacterial endotoxins

Symptoms

Pain (may be so severe that it

wakes the patient at night)

Red eye(s)

May be recurrent

Pain on EOM

Examination

Deep red colouration of anterior sclera - may be diffuse or

localised

Visual acuity may be normal

Scleral thinning associated with

bluish/black discolouration from

underlying uveal tissue

Treatment

Systemic corticosteroids/pu

lsed immunosuppressi

on for severe cases

Topical steroids as supplementary

therapy

Oral NSAIDs for mild cases

Complications

Visual loss

Scleral thinning

Perforation of the globe

Optic disc and

macular oedema

Intraocular inflamation

Uveitis

Endophthalmitis (infection

inside the eye)

Acute anterior uveitis (iritis)Inflammation of the iris

Uveitis cannot be accurately diagnosed without the aid of a slit-

lampCauses• Majority unknown, occurs

usually in 20-50 year age group

• May be associated with a systemic disease e.g HLA-B27, sarcoidosis

• May be associated with an infection e.g. herpetic, TB

Symptoms• Red eye (usually unilateral)• Pain• Blurred vision• Photophobia• NO discharge• NOT sticky

Examination

Circumcorneal

conjunctival injection

Keratic precipitates (inflammatory cells) on

corneal endotheliu

m

Examination

Flare (albumin leakage from iris vessels)

Inflammatory cells in the

anterior chamber -

hypopyon if severe

Miosis

Posterior synechiae (adhesions

between iris and lens)

Acute anterior uveitis (iritis)

Complications

May be associated with raised intraocular

pressure (IOP)

May become chronic and

develop secondary cataract +/-

macular oedema leading to reduced

vision

The condition is likely to recur and

in either eye

Treatment

Dilate pupil to prevent ciliary

spasm and break posterior synechiae

Intensive topical steroids, initially 1-

2 hourly then gradually reduce over next 4-6/52

In severe cases a subconjunctival

injection of steroid +/- mydricaine

(dilating agent) is necessary

Causes

High hyperopia

Advancing cataract

NOT related to

POAG

Symptoms

Nausea / vomiting

Painful red eye

Hazy vision

Haloes around bright lights

Examination

Hyperaemia +++

Fixed mid-dilated pupil

Hazy cornea

Epiphora

Complications

Rapid and complete visual loss

Aetiology is usually bilateral

Acute angle closure glaucoma

Acute angle closure glaucoma

Acute angle closure glaucoma

Palpate the eye to approximate IOP

Question 5:

What to do about floaters / flashing lights

Don’t panic – most cases will be a PVD

Could it be migraine??

If there is a retinal detachment – at BMEC: ‘Macula on’ – 24-48 hours ‘Macula off’ – 5-7 days

‘Macula On’ versus ‘Macula Off’

‘Macula On’ versus ‘Macula Off’

Other important conditions…..

Temporal arteritis

Causes

Spread of local infection• Sinusitis• Eyelis

Symptoms

Fever

Painful red eye

Eyelid swelling

Reduced vision

Diplopia

Examination

Engorged conjunctival

vessels

Conjunctival chemosis

Restricted EOM

Proptosis

RAPD

Complications

Optic nerve compression

Exposure keratitis

Rapid and complete visual

loss

Intra-cranial spread

Orbital cellulitis

Orbital cellulitis

Under active ophthalmic review

Sudden, painless visual loss

Please do not refer (if spontaneous)

Quiz

At 5 pm on a Thursday afternoon…….

68 year-old woman Previous right eye retinal

detachment 2 days history of left flashing lights /

floaters Right VA 6/36, Left VA 6/9 Pupil reactions normal

At 11 am on a Friday morning…….

76 year-old woman Hypermetrope ‘Optician says I have cataracts in both

eyes’ 2 months intermittent left eye pain,

redness and hazy vision Right VA 6/12, Left VA 6/24 Pupil reactions normal

Quiz

At 9 am on a Monday morning…….

26 year-old man Awoke this morning with a painful, red left

eye ‘Short-sighted’ Slept in contact lenses overnight from

Saturday Right VA 6/12, Left VA 6/18 (wearing old

specs) Pupil reactions normal

Quiz

At 2 pm on a Monday afternoon…….

26 year-old man 1 week history of red, gritty eyes and

discharge Partner had sore throat and ‘flu

symptoms Baby daughter recently had red eyes Right VA 6/9, Left VA 6/9 Pupil reactions normal

Quiz

At 6 pm on a Tuesday afternoon…….

36 year-old man Recent nose bleeds and short of breath Difficulty with left hearing Past 3 days unable to sleep with painful,

red right eye and some photophobia No response with paracetamol /ibuprofen Right VA 6/12, Left VA 6/9 Pupil reactions normal

Quiz

At 10 am on a Tuesday morning…….

76 year-old woman Feeling generally unwell, off food, losing

weight, difficulty sleeping Night sweats 2 weeks Headache Right VA 6/9, Left VA 6/9 Pupil reactions normal

Quiz

Key Points

Purulent discharge = bacterial infection Photophobia = keratitis, uveitis Reduced vision = keratitis, uveitis, angle

closure glaucoma Pain = scleritis, angle closure glaucoma,

keratitis, uveitis Hazy cornea = angle closure glaucoma,

keratitis, uveitis Contact lens wearer and sticky eye =

must exclude bacterial keratitis

In summary: easy ‘rules of thumb’

VA and pupil examination are crucial

Refer any CL wearer with red eye or pain

Become familiar with a limited range of lubricant drops and stick to them

If giving drops >4x/day then they should be PF (preservative free)

In summary: easy ‘rules of thumb’

Please don’t prescribe ocular topical steroids in primary care – great potential for ‘disaster’ Please do provide topical steroids if ongoing eye review

Squinting children Recent onset: refer urgently to eye cas Long-standing: refer to clinic

Temporal arteritis No visual symptoms – refer to rheumatology Visual symptoms – refer to ophthalmology