Examining the Eyes. Mr. Nicholas Lee Lead Clinician Consultant Ophthalmologist at Hillingdon and The Western Eye Hospitals

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1 Examining the Eyes Mr. Nicholas Lee Lead Clinician Consultant Ophthalmologist at Hillingdon and The Western Eye Hospitals

2 Ophthalmology - Eyes Ophthalmology Medical - Busiest outpatient department Glaucoma Diabetes National Screening Program Age related macular degeneration Surgical Cataracts commonest operation in UK Cosmetic refractive, Neuro-Ophthalmology Oculo-Plastics Paediatric Ophthalmology Orthoptists Health Visitors screening Optometrists Opticians

3 History It is all in the history! 3500 diagnoses in Ophthalmology Focus on part of eye affected POH PMH Drugs Eye Drops

4 History Symptoms point to the area of the eye involved Eg red painful, photophobic Right eye? Uveitis Sticky yellow/green discharge both eyes, no pain probably bacterial conjunctivitis Sudden loss of all vision? Central retinal artery occlusion or branch retinal vein occlusion? Distorted vision? Age related macular degeneration Blurred vision non-descript symptom

5 Specific questions How long as the vision been blurred, Did it become blurred overnight eg vascular, or take months eg cataract? POH eg Operations, previous hospital visits Look at old correspondence is this new? PMH eg diabetic Drugs eg Tamoxifen toxicity etc..

6 Differential diagnosis You should now have some idea of the problem Focused Examination

7 Example Patient MP Patient has blind left eye from retinal detachment. Wakes with blurring, soreness and Puffiness. Vision quickly recovers Sees General Practitioner concerned about retinal detachment General Practitioner refers urgently requesting same day appointment. Patient seen in eye dept Normal eye examination.

8 Example Patient What should the General Practitioner have done? Examined the Patient For eyes this means Measured Vision Dilated the pupil Examine back of eye and periphery with ophthalmoscope. Examination normal No referral Advice on retinal detachment signs Flashing lights, Floaters, cloud over vision Emphasised regular assessment by Optometrist. Consider routine referral to clinic if still concerned.

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10 Vision Essential!! Essential With their Glasses Snellen eg 6/6 LogMar eg 0 Counting fingers Hand movements Perception of light NPL

11 Examination External Eye movements Pupil reactions Slit lamp Intraocular pressure IOP Tono pens portable Fundus DILATE!!!

12 Fundal Examination

13 Fundal examination Dilate Tropicamide Phenylephrine Ophthalmoscope Slit lamp with 90D lens Slit lamp with contact lenses Fundal Cameras

14 Modern Eye Room

15 Modern High Tech Eye Department

16 Ophthalmology Team Ophthalmology Medical - Busiest outpatient department in hospital! Surgical Glaucoma Prof Bloom Medical Retina Diabetes Mr. Lee National Screening Program PCT/Mr. Khan Age related macular degeneration Lucentis No1 drug cost Vein/arterial occlusions - Mr. Sim Cataracts commonest operation in UK 300,000 /yr Neuro-Ophthalmology Oculo-Plastics Miss Rajni Jain Mount Vernon Hospital Paediatric Ophthalmology - Miss Siobhan Wren Orthoptists Health Visitors screening Optometrists Screening role/ dilating problem, management Varies from Optometrist that take an hour to those that spend 10 minutes, Know you local optometrists Quote this am We do not dilate pupils that is why we are sending you to the hospital Low Visual Aid clinic 3 in community & 1 Hospital

17 Ophthalmology Team NHS Constraints Busy 28,000 Patients per year Operations per year 100+ Lucentis/Avastin injections/month 18 Week pathway Has Reduced waiting times 200 Evening clinics last yr List one cataract at time, Reducing new to Follow up pathway PCT pressure to Discharge NICE Guidance Improving quality of care Wet AMD PDT & Lucentis Require monthly F/U Diabetic Screening NSF National guidance Glaucoma NICE Gudiance Refer all over 21mmHG Holistic care reduced in NHS Patients request annual reviews etc. One DNA discharged Work as Large team, teaching, training.

18 Referral Options True Emergencies Eye Clinic - Same day referral (No Sat Clinic) Out of Hours WEH A&E (General accident and emergency department NO!) Opticians possibly but will probably have to refer on. Routine Referrals Choose and Book Letters RMC Top copies of Optometrist report/photos

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