Dr Sean Every Ophthalmologist Southern Eye Specialists Christchurch Dr Jo-Anne Pon Ophthalmologist Southern Eye Specialists, Christchurch Hospital, Christchurch 8:30-9:25 WS #70: Eye Essentials for GPs 9:35-10:30 WS #80: Eye Essentials for GPs (Repeated)
Eye Essentials for GPs Diagnose important red eye conditions with confidence
Red Eyes Trauma Chemical injury Penetrating injury Corneal abrasion Foreign body Closed angle glaucoma Uveitis Conjunctivitis Allergies External hordeolum (stye) Dry eyes / blepharitis Subconjunctival haemorrhage Pterygium, pingueculum Episcleritis Keratitis Herpes Bacterial Contact lens related Scleritis
Name 4 Red Flag Symptoms
Red Flag Symptoms Significant Pain Reduced vision Severe photophobia Unilateral Previous history Iritis Herpes keratitis Previous / recent eye surgery Trauma
Chemical Injury True ophthalmic emergency IMMEDIATE washout (Alkali chemicals penetrate in <1 minute) Prolonged washout No litmus paper, irrigate for 20min Get under upper lid Topical Local Anaesthetic Limbal ischaemia poor prognosis i.e. eye not red Conjunctival chemosis (oedema)
What is the diagnosis? Cornea? Iris detail? Vision? Pain? Pupil fixed What to do next? Ballot the eye Slit-lamp beam
Clues
Angle Closure Glaucoma (ACG) Pain severe, headache Vision reduced +++ Haloes around lights Marked photophobia Unilateral Nausea and vomiting Marked red eye, ciliary Cornea hazy Iris detail obscured Pupil fixed, mid dilated Eye feels firm
Acute Angle Closure Glaucoma
Mechanism of glaucoma
Peripheral Iridotomy
Drugs that precipitate ACG in predisposed patients Dilating drops Tricyclic antidepressants MAOI Antihistamines Antiparkinsonian drugs Antipsychotic medications Antispasmolytic agents Who at risk? Older Asian High plus prescription (hypermetrope)
Glaucoma Most commonly open angle GPs cannot diagnose OAG Asymptomatic Can even have good visual acuity Don t falsely reassure your patients Optometrist or ophthalmologist Measure IOP Visual field test Examine Optic Nerve Monitor progression
What is the diagnosis? 1. 2.
Multiple choice: A. Iritis B. Subconjunctival haemorrhage C. Scleritis D. Episcleritis 1. 2.
1. Iritis 2. Subconjunctival haemorrhage Circumcorneal injection, ciliary injection Pupil not round posterior synechiae
Signs of iritis (anterior uveitis) Posterior synechiae Hypopyon
Hyphaema - Trauma Hypopyon - Inflammation - infection
Iritis / uveitis Unilateral or bilateral Pain variable Mild to severe Ache with focusing on near target (ciliary muscle inflammed) Won t settle with topical local anaesthetic Pupil sluggish and irregular Cornea clear or light haze Systemic inflammatory condition E.g. Ulcerative colitis Previous history Recurrent episodes HLA B27 Red eye ciliary pattern
What is the diagnosis? 2 1 3
What is the diagnosis? 1. HSK 1. HSK Non specific punctate staining A few linear lesions 3. Corneal abrasion? Not 3. HSK
Herpes Simplex Keratitis (HSK) 1. HSK 1. HSK Non specific punctate staining A few linear lesions 3. Corneal abrasion? Not 3. HSK Dendritic lesion typical Masquerader Fluorescein and cobalt blue light Disciform (stromal keratitis) Uveitis No fluorescein staining
Herpes Simplex Keratitis Pain (or not as much as expect affects corneal innervation) Red eye Photophobia Vision affected unless peripheral lesion Recurrent episodes, even years apart Treatment Oc acyclovir (gancyclovir) Vision threatening complications Scar Thinning of cornea
What is the diagnosis? 1. 2.
Keratitis ulcers, infiltrates - Bacterial, Fungal, Viral, Acanthamoeba - Contact lenses wearer - Poor eye closure 1. 2.
What is the diagnosis? Corneal rust ring Corneal abrasion Penetrating Eye Injury?? red eye may be mild
What is the diagnosis? Herpes Zoster Ophthalmicus Refer which HZO patients? Clinical sign to help you decide?
Herpes Zoster Ophthalmicus Hutchinson s sign vesicles at the tip of the nose (nasociliary nerve that supplies cornea) 1/3 without this can have ocular complications Conjunctivitis, Non-specific keratitis Common Self-limiting Acyclovir 800mg 5 times per day
Herpes Zoster Ophthalmicus Sight-threatening complications Corneal stromal inflammation Uveitis More common 1-2 weeks after onset of vesicular rash Helpful clinical signs: Reduced vision Corneal epithelial defect Vesicles at tip of nose
Giant Cell Arteritis Sudden or transient loss of vision Diplopia Usually >60yrs Suspicious Treat 1mg per kg 60mg + New onset headache Scalp tenderness Jaw claudication PMR symptoms Constitutional symptoms Unexplained weight loss Loss of appetite Fevers, night sweats
Red Eye Red Flag Symptoms Vision deterioration Severe pain Severe photophobia Unilateral History Observations of clinical signs