GRADUAL LOSS OF VISION. Teresa Anthony Consultant Ophthalmologist Emersons Green NHS Treatment Centre Bristol

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1 GRADUAL LOSS OF VISION Teresa Anthony Consultant Ophthalmologist Emersons Green NHS Treatment Centre Bristol

2 CVI Registration Low Vision: <6/18 but >6/60 Sight impaired: <6/60 but >3/60 Severe sight impaired: <3/60

3 CAUSES Refractive error Cataract Cornea Chronic Open angle glaucoma Diabetic Retinopathy Drug toxicity Age-related macular degeneration Optic nerve compression Hereditary Retinal degenerations

4 EFFECTS OF VISUAL LOSS High risk of depression Social withdrawal Isolation Disturbing hallucinations Risk of Falls Risk of self-medication errors

5 HISTORY Usually painless Uniocular or binocular Duration Previous ocular disease Present medications: Ocular and Systemic Diabetes and Hypertension Family history of Glaucoma

ERROR PUPIL PERLA RAPD FUNDOSCOPY FUNDOSCOPY HAZY VIEW CLEAR RETINAL VIEW NORMAL

6 Gradual Visual Loss VISUAL ACUITY REDUCED REDUCED AND DISTORTED PINHOLE AMSLER GRID NORMAL REDUCED MACULA REFR. ERROR PUPIL PERLA RAPD FUNDOSCOPY FUNDOSCOPY HAZY VIEW CLEAR RETINAL VIEW NORMAL RETINA ABNORMAL RETINA OPTIC NERVE RETINAL ABNORMALITIES MEDIA OPACITY - CORNEA, CATARACT, VITREOUS HEMORRHAGE AMD, DR, RETINAL DEGENERATIONS, DYSTROPHIES

7 REFRACTIVE ERROR Myopia Hypermetropia Astigmatism

8 AMBLYOPIA

9 MALINGERING History Attitude Visual Acuity Pupils Menace reflex Finger to Finger test

10 YOUR ROLE History Visual Acuity Pupils Social History Routine referral to optician

11 CORNEA Dry eye Laser refractive surgery Corneal dystrophies Pterygium Wilson s disease

12 DRY EYE Irritable eye Watery eye Schirmer`s test Fluorescein stain Blepharitis

13 YOUR ROLE Visual Acuity Blepharitis advice: Warm flannels and lid hygiene Ocular Lubricants Sometimes, preservative free eye drops

14 Management: Avoid Sun and wind Ocular Lubricants Steroid drops Surgery: Interfering with contact lens wear Encroaching on visual axis PTERYGIUM

15 MAP DOT FINGERPRINT DYSTROPHY Bilateral Recurrent Erosions Treatment: Ocular Lubricants Keratectomy

16 FUCHS ENDOTHELIAL DYSTROPHY

17 GLAUCOMA In England and Wales, it's estimated that more than 500,000 people have glaucoma but many more people may not know they have the condition. Chronic open-angle glaucoma affects up to two in every 100 people over 40 years old and around five in every 100 people over 80 years old. 10% of blindness in UK

18 Primary open angle glaucoma Raised IOP Visual field defect Optic disc cupping

19 GLAUCOMA - risk factors Increasing age Raised IOP High Myopia Peripapillary changes Positive family history Central corneal thinness Ethnicity 3 to 4 times more in Afro-Caribbeans

20 GLAUCOMA

21 OPTIC DISC CHANGES

22 YOUR ROLE Family History Visual Acuity Pupils Visual Fields Fundoscopy Routine Referral

23 DIABETIC RETINOPATHY Up to 10% of newly diagnosed Diabetics will have Retinopathy within 1 year Severe NPDR progression to: Threatening PDR within 1 year is 50 to 75% Increased risk of progression related to Duration of diabetes, Pregnancy, intraocular surgery

DIABETIC RETINOPATHY DIABETIC RETINOPATHY NON-PROLIFERATIVE PROLIFERATIVE MACULOPATHY BACKGROUND PRE-PROLIFERATIVE Neovascularisation of iris and/or Disc

24 DIABETIC RETINOPATHY DIABETIC RETINOPATHY NON-PROLIFERATIVE PROLIFERATIVE MACULOPATHY BACKGROUND PRE-PROLIFERATIVE Neovascularisation of iris and/or Disc and/or periphery Exudates Oedema Dot and blot haemorrhages Microaneurysms Hard exudates Cotton wool spots Vitreous hemorrhage Traction Retinal detachment

25 PROGNOSIS UNTREATED: 50% blind in 2 years 90% blind in 10 years TREATED WITH PRP: 50% reduction in visual loss

26 YOUR ROLE Medical management-bs, BP, Lipids Annual screening Visual acuity Pupils Amsler grid Fundoscopy Colour vision

27 MACULA DEGENERATION Leading cause of Age-related sight loss in UK 60% blindness over 65 years of age: DRY: 80% WET: 20% Prevalence 513,000 set to rise to 700,000 by 2020

28 RISK OF AMD Age Family history Hypertension Hyperlipidemia Smoking Caucasian

29 AMD

30 PROGRESSION OF AMD DRY---slow WET---faster

31 YOUR ROLE History Symptoms scotoma, metamorphopsia Medical management: BP, lipids Advise to stop smoking Visual acuity Pupils Amsler grid Refer urgently: Amsler abnormal

32 CATARACT

33 CATARACT 50% of blindness worldwide 30% over the age of 65 55% hereditary ,000 surgeries done ,000 surgeries done

34 DOH Action on Cataracts 1. The cataract affects sight 2. Reduced vision has a negative impact on Quality of life 3. Understands Risks and Benefits of surgery 4. ACTION ON CATARACT did not establish visual acuity threshold

35 CATARACT REFERRAL Optometrist---GP/Choose and Book-- Consultant Direct Referral pathway from Opticians South Gloucestershire--Cataract score.

36 SECOND EYE SURGERY In 12 months following surgery Fewer falls(18% vs 25% ) Fewer fractures( 3% vs 12%) Compared to routine surgery after 12months

37 INDICATIONS FOR SURGERY Affecting quality of life Surgical therapy for Lens-related Glaucoma To facilitate management of ocular disease; ie Diabetic retinopathy

38 MANAGEMENT Refraction Surgery

39 INTRAOCULAR LENS IMPLANT Monofocal Multifocal Accomodative Astigmatic Toric

40 MONOFOCAL LENS IMPLANT

41 Commonest MONOFOCAL IMPLANTS Corrects distance vision but will need glasses for reading

42 MULTIFOCAL Similar to Varifocals Focuses at all distances

43 ACCOMODATIVE Correct distance and intermediate distance Not as strong for near vision

44 TORIC Corrects ASTIGMATISM

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Maximising the use of resources- One stop cataract surgery A proposed new model 1. L Z Heng; 2. Y. Tashter; 2. T Anthony 1. Bristol Eye Hospital ; 2.

Conventional pathway for cataract surgery for both eyes consists of minimum of 6 ophthalmic visits.

Given the cost-savings potential, the aim of this prospective study was to analyse the objective rates of patient listing, cost savings and patient satisfaction in a proposed new model of a One-stop

1 Over 2 year period in 1 consultant day list Total One-Stop Cataract Patient Seen Total one-stop Cataract Patient Procedure Done Quantity in numbers (proportion %) 1020 983 (96.

51 Maximising the use of resources- One stop cataract surgery A proposed new model 1. L Z Heng; 2. Y. Tashter; 2. T Anthony 1. Bristol Eye Hospital ; 2. Emersons Green Treatment Centre Rationalising resources in the National Health Services(NHS) has potential to compromise current cataract surgical treatments. Conventional pathway for cataract surgery for both eyes consists of minimum of 6 ophthalmic visits. The One-stop pathway is not a foreign concept, but previous models showed low listing rates and poor patient satisfaction. Given the cost-savings potential, the aim of this prospective study was to analyse the objective rates of patient listing, cost savings and patient satisfaction in a proposed new model of a One-stop pathway for routine cataract surgeries. 1 Over 2 year period in 1 consultant day list Total One-Stop Cataract Patient Seen Total one-stop Cataract Patient Procedure Done Quantity in numbers (proportion %) (96.37%) Total aborted procedures 37 (3.63%) Average number of 11.3 procedures per day list Maximum number operated in 1 day list Minimum number on day list Average time from time in to discharge/min *of 37 aborted procedures, 9 were referred to tertiary centers due to complexity of case, and other cited reasons included high INR and blepharitis. * The proposed model consists of 2 hospital visits and 1 telephone consultation by a trained nurse. Hospital visits consisted of consultant-led visit with simultaneous preoperative assessment/surgery for first eye; 2 nd eye pre-operative assessment and surgery/ 1 st eye follow up and 2 nd eye surgery. (Figure 1 and 2). Satisfaction surveys were distributed to patients at final visit. Patients were followed up between November 2014 to November Listing rates for patients were tabulated at each session. Reasons for ineligibility were recorded. Patient feedback Exclusion criteria: BMI more than 44 BP above 180/100 Cardiology problems within last 6 months Stroke within last 6 months Epileptic seizure within last 6 months INR above 3.5 uncontrolled Diabetes HbA1c above 69mmol/mol = Blood sugar above 17mmol Traumatic Cataracts Patients wanting multifocal implants Previous Laser refractive surgert Patients were also asked to grade satisfaction with the one stop model, with one being least satisfied, and 5 very satisfied. 97.1% (n=67) patients gave a rating of to the current model. Compared to prior studies, the proposed model has demonstrated a higher rate of successful listing. A proposed reason for resistance to one-stop surgery could be because of the reduced income from payment only for surgery. However, given the long term outlook for rationalisation of limited NHS resources, alternative feasible cost saving models such as the current study needs to be seriously considered. We propose larger scale studies with economic analysis of savings with current model. References: 1. Evans et al, One-stop cataract clinics: feasible but flawed? Eye (2004) 18, Prasad et al. Optimisation of outpatient resource utilisation in cataract management. Eye 1998; 12:

52 YOUR ROLE History ocular[ refractive surgery], only eye Visual acuity Pupils Fundoscopy red reflex General health Medications: warfarin, Tamsulosin Allergies Social

53 DRUG TOXICITY Chloroquine Hydroxychloroquine Amiodarone Steroids Chlorpromazine Ethambutol

54 Visually asymptomatic AMIODARONE Discontinuation not indicated

55 CHLOROQUINE TOXICITY Dose to produce toxicity :>300g total cumulative dose Hydroxychloroquine: >750mg/day taken over months to years SYMPTOMS: blurred vision, abnormal colour vision, delayed dark adaptation TREATMENT: Discontinue medication PROGNOSIS: does not recover after discontinuing

56 CHLOROQUINE MACULOPATHY Bull`s Eye Maculopathy

57 YOUR ROLE Visual acuity Colour vision Fundoscopy Amsler grid more sensitive than visual fields Routine referral to Ophthalmologist

58 TOBACCO/ALCOHOL AMBLYOPIA Bilateral No RAPD Reduced Colour vision Visual field: Centrocaecal defect Pale Optic disc, mainly temporal pallor

59 TOBACCO/ALCOHOL AMBLYOPIA Excessive intake of tobacco and/or alcohol

60 YOUR ROLE Visual acuity Pupils Colour vision Fundoscopy Advise to stop smoking and alcohol Serum Vitamin B12 level Vitamin B12, 1000micrgms.,i.m.monthly Follow-up 6monthly

61 OPTIC NERVE COMPRESSION Headaches RAPD Visual field defects Optic nerve swelling or pallor Neurological abnormality Endocrine abnormality

62 RETINITIS PIGMENTOSA X-linked recessive Degeneration of Rod cells and retinal atrophy Night blindness Family history

63 CONE-ROD DYSTROPHY Positive family history Decreased colour vision Delayed dark adaptation ERG

64 RETINAL DEGENERATIONS Visual acuity Pupils Visual fields Colour vision Routine referral Genetic counselling Low vision aids CVI registration YOUR ROLE

65 VISUAL PATHWAY PROBLEMS Optic nerve unilateral loss Chiasma bitemporal hemianopia Optic tract homonymous hemianopia RAPD Field test

66 CORTICAL BLINDNESS Bilateral severe visual loss in the presence of normal pupils Confirm--MRI

67 ECTROPION

68 ENTROPION

69 Thank you

Mild NPDR. Moderate NPDR. Severe NPDR

Mild NPDR. Moderate NPDR. Severe NPDR Diabetic retinopathy Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years-old. Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in