The art of coarse Ophthalmology

Alistair BennettDyfed road health centre

NEATH!NEATH!NEATH!

Main topics

• History and examination

• Red eyes

• Visual disturbance and loss

• Cold cases

• Social aspects

• Refractive surgery

J`accuse

• Poor undergraduate teaching

• Poor postgraduate teaching

• Snellen charts

• Medical short cases

• A different language with confusing terminology

• Textbooks with endless pictures of red eyes

History

• Does it hurt ?

• Can you see clearly

• Foreign body

• timescale

History

• PAIN

• VISUAL DISTURBANCE

Visual disturbancesymptoms

• Distortion

• Haloes

• Floaters

• Flashes

• Diploplia

Distortion

• Kinks

• Amsler chart

• Metamorphopsia

• IT`S A MACULAR THING

Floaters

• Spots

• Blobs

• Flies

• Cobwebs

• IT`S A VITREOUS THING

Photopsia

• Flashing lights

• If it ain`t migraine IT`S A RETINAL THING

Haloes

• Acute angle closure (spectral)

• Monochromic(cataract)

Examination

• Record VA

• If you do nothing else record VA

• Use a pinhole

Visual acuity

• CF

• HM

• PTL

• NPTL

Examination

• Outside in

• Fundus last and with a differential diagnosis in mind

• Do not expect to see anything through an undilated pupil

Red eye

• If pain and or reduced VA

• Eye casualty

Visual loss/disturbance

• Sudden visual loss

• Sudden blurring

• Gradual blurring

• Double vision

Sudden visual loss

• CRA occlusion

• CRV occlusion

• Macular haemorrhage

• Retinal detachment

• Migraine

• Amaurosis fugax

Gradual blurring

• Cataract

• Age related macular degeneration

Distorted vision

• Wet ARMD

• Macular hole

• Cellophane maculopathy

Flashes and floaters

• Posterior vitreous detachment

• Vitreous haemorrhage

• Retinal hole

• Retinal detachment

• migraine

Retinal Detachment

• Sudden onset floaters

• Intermittent flashing lights

• Within 24 hours

• Peripheral shadow or curtain coming down

• Same day

Binocular double vision

• Cranial nerve palsy

• Blow-out fracture

Cold ophthalmology

• Cataracts

• Primary open angle glaucoma

• Age related macular degeneration

Cataract symptoms

• Gradual mist / clouding

• Gradual decrease VA

• Myopic shift

• Glare

• Monocular diploplia

Cataract surgery

• Day case regional anaesthetic

• Corticosteroids for 3 weeks

• Optician for refraction 6 weeks

Cataract surgery complications

• Posterior capsule rupture

• Lens fragment in vitreous

• Endophthalmitis

• Retinal detachment

• Pain should become less and vision improve every day in the immediate post-op period

If it ain`t broke don`t fix it

• 2 in 100 worse off

• 1 in 1500 blind

• 1 in 14000 sympathetic ophthalmitis

Indications for surgery

• Only when cataract visually significant and the benefits outweigh the risks

• Can patient read,drive,satisfy DVLA standard,faces,steps,kerbs

Conservative measures

• Refraction for myopic shift

• Sunglasses and a hat with a brim for glare

• Large print

• Light behind

• Talking books

Primary open angle glaucoma

• It’s a triad

• Raised IOP (normal <21mmHg)

• Optic disc cupping

• Visual field defects

• Asymptomatic

• Picked up by optician

Occular hypertension

• IOP>21mmHg (2SD)

• Important risk factor for glaucoma

• 10% over 10 years

• Remember normal tension glaucoma

ARMD

• Age related macular degeneration

• Commonest cause of blindness in uk

• Dry and wet types

• Wet type “treatable” infact prevents rapid decline

• Wet type can develop on dry type

ARMD exudative/wet type

• Amsler distortion

• Metamorphopsia

• Sudden deteriation

Wet Type AMD Treatments

• Macugen (pegaptanib)

• Lucentis ( ranibizumab)

• Monoclonal antibodies against the vascular endothelial growth factor

Wet AND treatments

• Early studies encouraging

• May halt or slow deteriation in some patients

• Administered by intravitreal injections every 4-6 weeks for life

• Considerable cost

ARMD referral

• Confirmation of diagnosis

• L.V.A

• Registration

• Co-morbidity

• Wet type

Social aspectsvisual impairment registration

• Registration triggers both social services and voluntary group support

• Adaptations to house,visual aids,tapes and large print books

• Social worker visit• Benefits DLA/AA,housing benefit,tax

allowances• Free prescriptions/sight tests• Rail telephone concessions

Quality of life and visual rehabilitation: an observational study of low vision in General Practice in West Glamorgan

Eye 2006, Williams, Austin Bennett et al

Main Findings

• 66 patients

• 85% over 70 years

• 70% female

• 80% received a visit from social services

• 33% still in contact with social services

• 36% had a white stick

• None had a guide dog

Main Findings

• 66% had to negotiate steps to front door

• 36% had mobility and safety aids (handrails etc)

• 44% speaking clock

• 41% lived alone

Charles Bonnet Syndrome

• Visual hallucinations in those with visual impairment

• Simple patterns and lines to complex pictures

• Can be distressing but not confused with reality

Full blind registration

• Vision must be worse than 3/60 in both eyes

• OR

• Vision worse than 6/60 in both eyes with restricted field

Partial sight registration

• Vision worse than 6/60 in both eyes

• Vision worse than 6/18 in both eyes with a restricted field

• hemianopias

DVLA standards

• Number plate at 20.5 metres

• Visual field 60 degrees either side of fixation

Smoking and the Eye

• AMD

• Glaucoma

• Cataracts

• CRVO

• Ischaemic neuropathy

• Diabetic retinopathy

Vitamin supplements

• Some studies have suggested that zinc, anti-oxidants and vitamin supplements can slow the progression of dry AMD

• Effect small

• Marketing of supplements e.g. I-Caps

Refractive Laser Surgery

• PRK photorefractive keratectomy

• LASEK laser epithelial keratomilieusis

• LASIK laser in situ keratomilieusis

• ETC

Complications

• www.rcophth.ac.uk/about/public/laser• Dry/sensitive eyes• Presbyopia• Minor refractive error• Anisometropia• Infection• Decreased night vision, glare, haloes,

starburst

Drugs with Occular side Effects

• Vigabatrin

• Tamoxifen

• Chloroquine

• Amiodarone

• ethambutol

78 year old man, hypertensive smoker, sudden loss of vision right eye, fundoscopy normal

Central retinal artery occlusion

Patient complaining of flashing lights 3 days ago and now a

shadow when looking in certain directions

Gradually deteriorating vision 6 months. Can’t see fundus

80 year old lady struggling to read and see faces, good red

reflex

Young, bilat red eyes lid oedema watery discharge

35 male photophobia, red eye, blurred vision

70 yrs female headache vomiting brow pain

Itchy, gritty sore eyes nil to see