Dr Bruce Davies
You are not alone!
A very popular topic
How much time at medical school?
What do the acuity numbers mean!
One or both?
What disturbance of vision?
Rate of onset?
Any blind spots?
Any associated symptoms e.g. floaters?
Exactly what is worrying the patient.
Contact lens use?
Myopia? (increases risk of retinal detachment
Any family history? (FH of glaucoma in a 1st
degree relative gives you a 1/10 lifetime risk, or
Any history of diabetes, hypertension or
connective tissue disease?
Snellan chart, 3m or 6m, simple text for near vision,
Fields, remember red and the quality of the red, simple 4
Pupils: a bright torch and magnifying glass
Opthalmoscopy: Start at 10, red reflex?, green filter
enhances blood vessels, dilate prn, risk of acute closed
angle glaucoma remote.
Lids and tears
Slow visual loss in the quiet eye
Squints, new and congenital, rare
…..(then a rare specialist rag bag)
Commonest, an uncomfortable red eye.
Discomfort. Purulent discharge. Spreads from
one eye to the other. Vision normal. Uniform
engorgement Chloramphenicol first choice (?)
Often with an URTI. Gritty. Discomfort.
Watery discharge. May last many
Photophobia. Small corneal opacities
may develop. Prolonged (often
adenoviral) may need specialist therapy
with steroids. Chloramphenicol to
prevent 2nd infection.
Mucopurulent, cornea inflamed, visual loss. Often
with STD. Permanent damage possible, topical and?
systemic tetracyclines. Refer.
Less than one month is notifiable disease - any
cause. May lead to scarring and permanent damage.
Itching and discomfort. Chemosis and visual acuity
loss possible. Papillae and if big cobblestones.
Cromoglycate may take days to start to work if bad.
Red sore eye. No discharge. Localised (viz.
Episcleritis usually self limiting and idiopathic,
no treatment needed.
Scleritis often with CT diseases, dangerous
(perforation possible) Refer.
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.
The uveal tract. So iritis, iridocyclitis and anterior
uveitis are synonyms.
At risk: HLA-B27, CT diseases, past attacks, juvenile
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
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
Lids and tears
= meibomnian cyst. In the lid. Warm
compresses and chloramphenicol.
Persistent - incise.
Recurrent: ? DM, ? blepharitis, ?
Can cause astigmatism from pressure.
An infection of lash follicle. May be head
of pus - nick with needle. Or warm
compresses and chloramphenicol.
Non infected cysts from sweat or
sebaceous lid glands, if a problem can
often be simply treated with a nick with
a needle - small.
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 ointment[tetracycline], artificial
tears ? oral tetracyclines
Medial inflammation over lacrimal sac.
Refer, systemic therapy and topical
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
Watery eye.. Laxity from age or nerve palsy.
Ointment and refer for LA operation to correct.
Common especially in the elderly. Scarring from the
Often results from blepharitis or chronic conjunctivitis
Damage to lids. May be removed but
will often need electrolysis or
cryocautery to prevent recurrence.
Remember to treat associated
An easy list really as
they all need
Floaters, photopsias, the shadow or curtain across
More women, pain on moving the eye, central
Posterior vitreous detachment
Aged 50+, flashing lights, floaters
Floaters, red haze may be present. Red reflex
•Sudden disturbance of central vision.
•Field loss. Diabetes, hypertension
•Youth, headache, zigzag lines, multicoloured lights.
•Elderly, bilateral loss.
Slow visual loss
Refer to optician then ? refer.
Unless really trivial
Remember the orthoptist
Can you do a cover test?