Eyes
Dr Bruce Davies
You are not alone!
A very popular topic
How much time at medical school?
What do the acuity numbers mean!
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.
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?
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.
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)
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 (?)
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.
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.
Episcleritis /
scleritis
Red sore eye. No discharge. Localised (viz.
conjunctivitis=generalised) inflammation.
Episcleritis usually self limiting and idiopathic,
no treatment needed.
Scleritis often with CT diseases, dangerous
(perforation possible) Refer.
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.
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.
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.
Lids and tears
Chalazion
= meibomnian cyst. In the lid. Warm
compresses and chloramphenicol.
Persistent - incise.
Recurrent: ? DM, ? blepharitis, ?
roseacea.
Can cause astigmatism from pressure.
Stye
An infection of lash follicle. May be head
of pus - nick with needle. Or warm
compresses and chloramphenicol.
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.
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 ointment[tetracycline], artificial
tears ? oral tetracyclines
Acute dacrocystitis
Medial inflammation over lacrimal sac.
Refer, systemic therapy and topical
urgently.
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
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
Ingrowing lashes
Damage to lids. May be removed but
will often need electrolysis or
cryocautery to prevent recurrence.
Watering eyes
Differential diagnosis.-
your homework!
Dry eyes
Common,
Remember to treat associated
blepharitis
Sudden visual
loss
An easy list really as
they all need
specialist
assessment!
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.
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.
Slow visual loss
Refer to optician then ? refer.
Cataracts
Corneal opacities
Macular problems
Retinal problems
Trauma
Refer !
Unless really trivial
Squints
Refer
Remember the orthoptist
Can you do a cover test?