BMEC A&E and Urgent Care Clinic. Mr. K.S. Lett Consultant Ophthalmologist Clinical Lead for Emergency Eye Service And Vitreo-Retinal Service

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1 BMEC A&E and Urgent Care Clinic Mr. K.S. Lett Consultant Ophthalmologist Clinical Lead for Emergency Eye Service And Vitreo-Retinal Service

2 Overview Primary care BMEC Differentiating emergency, urgent and routine referrals Differentiating timing of urgent and routine cases Identify what emergency management can be instigated by optometrist Update access pathways and contact numbers

3 BMEC A&E 2 nd biggest & busiest Eye Cas in UK Covers Birmingham, Solihull, Sandwell, Dudley, Worcester, Redditch Covers further afield for some conditions Walk ins and referrals Open (Sunday 18.00) OOH City Hospital main A&E

4 Consultant Led Service Session Mon Tue Wed Thu Fri am Pandey Glaucoma Ghosh Plastics Lett VR Aralikatti Cornea Chavan MR pm Damato, Das Mellington Plastics Mitra VR Nessim Glaucoma El-Defrawy Paeds

5 Other Medical Staff Specialty doctors Subspecialist Fellows, junior & senior Vitreo-retinal Corneal Glaucoma Neuro-ophthalmology Uveitis Medical retina OSTs (ST 1-7) daytime On-call (1 st, 2 nd, 3 rd, 4 th )

6 Nursing Staff Alison Hynes, Sister in Charge Advanced nurse practitioners Staff nurses HCAs Clerical staff

7 Services Provided Assessment of all eye accidents & emergencies Urgent treatment medical, laser, surgical Urgent Care Clinics Mon Fri, Training Specialist doctors, GP registrars Nurses, Optometrists, Orthoptists Medical students

8 Pre-Triage System Red Amber Green OPD Need to be seen within a few hrs, further triaging. Need to be seen within 72 hrs, diverted to UCC slots. No need for urgent assessment, referred to GP, optometrist or to (via GP).

9 Red Very Urgent Penetrating eye injury Acute post-op endophthalmitis Severe chemical injury GCA with visual symptoms Sudden loss of vision <6hrs

10 Red - Urgent Orbital cellulitis Painful red eye with visual loss Retinal detachment with good VA Corneal ulcer, esp. with CL wear Blunt trauma with hyphaema & IOP Corneal graft rejection Painful diplopia

11 Amber Flashes & floaters, no loss of vision Red eye without severe pain or visual loss Retinal vein occlusions (OPD 4-6/52) Diabetic retinopathy with vitreous haemorrhage Wet AMD (preferably refer to Fast Track Macular Clinic)

12 Green GP Mx Bacterial & viral conjunctivitis Allergic conjunctivitis Blepharitis Dry eyes Lid lumps and bumps

13 Green OPD Referral Cataract Chronic / gradual visual loss (months) Open angle glaucoma, ocular hypertension Watery eyes Ectropion, entropion Lid lumps & bumps Non-acute diplopia

14 Trauma Burns Acid, alkali, thermal, arc eye Abrasions & lacerations Lid, corneal and conjunctival, PEIs Foreign bodies Corneal, conjunctival, sub-tarsal, intra-ocular Blunt trauma SCH, hyphaema, choroidal rupture OBF, TON

15 Chemical Injury Potential emergency Alkali or Acid ph check Immediate irrigation May result in limbal stem cell failure

16 Corneal Abrasion History provides indication of severity Doesn t always require A & E Oc. Chlor qid 5/7

17 Lid Laceration Refer to A & E Be mindful of additional injuries

18 Foreign Bodies Can be removed by optoms if confident g. Chlor qid 5/7 Refer if unable to remove or rust rings Always check for subtarsal FB as well

19 Penetrating Eye Injury Beware of intra-ocular FB Don t put pressure on globe

20 Intraocular Foreign Body Detailed history Determine composition of IOFB Influences urgency of surgery

21 Sub-conjunctival Haemorrhage Spotaneous vs traumatic Self limiting No treatment No referral required

22 Hyphaema Check IOP Risk of rebleed Risk of endothelial staining

23 Blow Out Fracture Assess for globe damage, TON Orbital surgery only if tissue entrapment Normally done within 4/52

24 Angle Recession Risk of glaucoma with increasing degree of recession Optometry monitoring

25 Iridodialysis Risk of glaucoma Phacodonesis Difficult surgical repair

26 Cornea Dry eye Recurrent erosion syndrome Pterygium Ulcers CL related Acanthamoeba Dendritic Shingles

27 Dry Eye Lubricants Look for blepharitis Refer if unable to improve symptoms

28 Recurrent Corneal Erosion Index injury Typically pain on waking / opening eyes Oc. Simple / Lacrilube nocte 3/12 Refer if no improvement

29 Pterygium Only require surgery if threatening visual axis Lubricants Routine referral

30 Bacterial Keratitis Esp in CL wearers Excess wear, poor hygiene Urgent referral Differentiate from marginal keratitis

31 Acanthamoeba Esp in CL wearers Hx of swimming, showering in lenses Non healing epithelial defect Pain disproportionate to signs Urgent referral

32 Dendritic Ulcer Typically HSV 1, as with cold sores Self limiting Treated with topical Acyclovir / Valgancyclovir UCC referral

33 Herpes Zoster Ophthalmicus Oral antiviral Rx if started within 48hrs onset of rash by GP Not always eye involvement Hutchinson s sign 70% chance eye involvement Most eye involvement doesn t require specialist Rx

34 Conjunctiva Conjunctivitis Bacterial, viral, allergic Episcleritis Scleritis

35 Bacterial Conjunctivitis Purulent / mucopurulent discharge Self limiting g. Chlor qid 1/52 No referral required

36 Viral Conjunctivitis Self limiting Watery discharge Follicular reaction No referral required unless corneal involvement

37 Allergic Conjunctivitis Identification and avoidance of trigger allergen Topical Sodium cromoglycate Oral anti-histamines No referral required unless persistent problem

38 Episcleritis Self limiting Mild Moderate discomfort Oral NSAIDs, eg ibuprofen No referral required unless persistence Steroid dependency

39 Scleritis Severe dull boring pain Strong association with autoimmune and connective tissue disease Urgent referral Needs extensive management

40 Lids Blepharitis Anterior, posterior Chalazion, stye Ectropion, entropion Pre-septal cellulitis

41 Anterior & Posterior Blepharitis Lid hygiene Hot compresses Treat associated dry eye No referral required

42 Chalazion Hot compresses GP to prescribe Abx if infected No referral to A & E

43 Senile Ectropion & Entropion Ensure lubrication of ocular surface No acute management in A & E GP to refer routinely

44 Pre-Septal Cellulitis Need to differentiate with orbital cellulitis Pt not systemically unwell No orbital signs Needs oral Abx (GP) Refer urgently if in doubt

45 Orbital Cellulitis Potentially sight / life threatening condition Emergency referral Pt systemically unwell, pyrexial Orbital signs Need admission and IV ABx

46 Neuro-ophthalmology III rd, IV th, VI th nerve palsies Optic neuritis Papilloedema Anisocoria Giant cell arteritis

47 3 rd, 4 th, 6 th Palsy Majority will be microvascular in elderly diabetic hypertensive population If so, routine referral Beware of painful nerve palsy esp 3 rd PCA aneurysm Beware of assoc headache esp 6 th GCA

48 Optic Neuritis, Papilloedema Unilateral vs bilateral Disc haemorrhages Both may require urgent referral (depending on duration of symptoms)

49 Anisocoria In light, larger pupil abnormal In dark, smaller pupil abnormal Ask if noticed before old photos, friends and family Urgency of referral depends on duration

50 Giant Cell Arteritis Temporal headache and tenderness Blurred vision Polymyalgia Associated with RAOs Emergency referral to Eye Cas ONLY if visual symptoms eg. Amaurosis Otherwise GP to refer urgently to Rheumatology / Physicians

51 Glaucoma AACG Neovascular What IOP is urgent? <35mmHg refer to outpatients >35mmHg refer to UCC / Eye Cas

52 Acute Angle Closure Glaucoma Typically presents midday onwards Fixed, semi-dilated pupil High pressure, corneal oedema Closed angle may need to examine fellow eye Emergency referral Needs medical treatment then laser PI More extensive surgery may be necessary

53 Iris rubeosis Due to ocular ischaemia Can be confused with dilated vessels in uveitis Needs UCC referral Likely to need pan retinal photocoagulation

54 Uveitis Anterior Intermediate Posterior Posner Schlossman Mild uveitis IOP Pain

55 Anterior Uveitis Cells, flare, KPs, PS Frequently recurrent cases Need UCC referral unless severe case, raised IOP, fibrin

56 Intermediate & Posterior Uveitis Intermediate often chronic Hx of floaters No retinal involvement If no reduction of acuity, routine referral Posterior normally severe rapid loss of vision. Retinal involvement Needs urgent referral

57 Vitreo-Retina PVD Vitreous haemorrhage Retinal tears and holes Retinal detachment Retinoschisis Epiretinal membrane & macular hole Dry & Wet AMD Vascular occlusions Proliferative diabetic retinopathy Central serous retinopathy

58 Posterior Vitreous Detachment Only 30-50% PVD symptomatic Look for tobacco dust Ensure not red blood cells Symptomatic PVD refer to UCC, depending on duration If tobacco dust refer to Eye Cas

59 Vitreous Haemorrhage Check for systemic associations eg. DM, HT, Sickle Examine fellow eye If present, UCC referral (duration dependent) In absence of systemic disease, PVD with VH has 80% incidence of retinal tear Urgent referral to Eye Cas

60 Retinal Breaks Horseshoe tears, U-tears Arrowhead tears Operculae Atrophic holes Giant retinal tears Dialysis

61 Lattice Degeneration Population incidence 10-15% Frequently seen with holes If asymptomatic, routine referral In vast majority of cases, no prophylactic treatment

62 Retinal Detachment Is the macula on or off? VA Clinical exam OCT If on, emergency referral If off, Eye Cas, UCC or clinic depending on duration Check for symptoms, signs of chronicity NOT ALL DETACHMENTS ARE AN EMERGENCY!

63

64 Retinoschisis Typically asymptomatic Immobile thin transparent retina No breaks Inner & or outer leaf breaks Frequently mirrored in fellow eye Routine clinic referral

65 AMD Dry vs Wet No referral for dry monitoring Wet refer via fast track system no need to send to Eye Cas / UCC

66 Epiretinal Membrane Insidious onset Only treatment is surgery Routine referral

67 Macular Hole Often present for considerable period of time before diagnosis Only treatment is surgery or in small number of cases, ocriplasmin Routine referral

68 Retinal Vein Occlusion No emergency treatment available Refer via fast track system Need long term treatment

69 Retinal Artery Occlusion Irreversible retinal damage from 4hrs of onset Immediate emergency treatment tried up to 8hrs from onset Aspirin ocular massage rebreathing into bag Beyond this time no heroic measures Check for GCA symptoms TIA referral from GP / UCC

70 Neovascular Retinopathy Most commonly diabetics Also Sickle, prior RVOs and rarely RAOs Refer to UCC unless also VH

71 Central Serous Retinopathy Typically young middle aged men Type A personalities Stress Self limiting <6/12 Treatment only if not resolving Routine referral

72 Contact Numbers Triage nurse Fax / 6711 Fast Track Macular / RVO Fax BMEC switchboard

73

74

75 Any Questions? Thank you

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