Eye conditions the GP can manage or should recognise"

Eye conditions the GP can manage or should recognise"

Mitch Menage

Consultant Eye Surgeon

Leeds Teaching Hospitals Trust

Mitch Menage

Consultant Eye Surgeon

Leeds Teaching Hospitals Trust

GP Meeting March 2014GP Meeting March 2014

BlepharitisBlepharitis

Chronic inflammation of the lid margins Common Remitting Range of ages Bilateral Often misdiagnosed as conjunctivitis

Chronic inflammation of the lid margins Common Remitting Range of ages Bilateral Often misdiagnosed as conjunctivitis

BlepharitisBlepharitisBlepharitisBlepharitis Lid anatomy Types Associated conditions Symptoms Signs Treatment

Lid anatomy Types Associated conditions Symptoms Signs Treatment

Lid anatomyLid anatomyMeibomian/tarsal glands

Glands of Zeiss and Moll

Lid anatomyLid anatomy

Blepharitis-TypesBlepharitis-Types

Anterior –staphylococcal/dandruff

Yellow flakes on lid margin

Posterior sebborhoeic Inflamed red oily lid edges

Anterior –staphylococcal/dandruff

Yellow flakes on lid margin

Posterior sebborhoeic Inflamed red oily lid edges

BlepharitisBlepharitis

Staphylococcal BlepharitisStaphylococcal Blepharitis

More common young patients Chronic infection of base of lashes Staph. Aureus Associated with styes Secondary

Papillary conjunctivitis Punctate corneal erosions Marginal keratitis

More common young patients Chronic infection of base of lashes Staph. Aureus Associated with styes Secondary

Papillary conjunctivitis Punctate corneal erosions Marginal keratitis

Seborrhoeic BlepharitisSeborrhoeic Blepharitis

More common older patients Excessive lipid secretion meibomian glands

Meibomitis/MGD

Lid commensals break down to free fatty acids Shiny waxy lids with greasy lashes Secondary

Papillary conjunctivitis Punctate corneal erosions

More common older patients Excessive lipid secretion meibomian glands

Meibomitis/MGD

Lid commensals break down to free fatty acids Shiny waxy lids with greasy lashes Secondary

Papillary conjunctivitis Punctate corneal erosions

Acne RosaceaAcne Rosacea

Strongly associated with seborrhoeic blepharitis Mild forms not diagnosed

Strongly associated with seborrhoeic blepharitis Mild forms not diagnosed

Blepharitis-SymptomsBlepharitis-SymptomsBlepharitis-SymptomsBlepharitis-Symptoms

Sore burning itching irritation of lids Grittiness and watering Mild stickiness particularly on waking Red lid margins Dry eyes

Sore burning itching irritation of lids Grittiness and watering Mild stickiness particularly on waking Red lid margins Dry eyes

SignsSignsSignsSigns

Red lid margins Greasy material along margin of lids Clogging of meibomian gland openings Mild conjunctival injection Punctate corneal staining Acne Rosacea Styes/chalazions

Red lid margins Greasy material along margin of lids Clogging of meibomian gland openings Mild conjunctival injection Punctate corneal staining Acne Rosacea Styes/chalazions

ChalazionChalazion

TreatmentTreatmentTreatmentTreatment

Patient education! Lid hygiene cotton buds/baby shampoo Hot compresses

Warm flannel 5 mins Eyebag

Lubricants Antibiotic gel/ointments Oral antibiotic Doxycycline/Limecycline

Intermittent steroid ointment

Patient education! Lid hygiene cotton buds/baby shampoo Hot compresses

Warm flannel 5 mins Eyebag

Lubricants Antibiotic gel/ointments Oral antibiotic Doxycycline/Limecycline

Intermittent steroid ointment

EyebagEyebag

www.eyebagcompany.com

Dry EyesDry EyesDry EyesDry Eyes

Lacrimal apparatus Tear Film Causes/Associated Conditions Symptoms Signs Treatment

Lacrimal apparatus Tear Film Causes/Associated Conditions Symptoms Signs Treatment

Lacrimal anatomyLacrimal anatomyLacrimal anatomyLacrimal anatomy

Tear filmTear filmTear filmTear film

Several layers Lipid outer Aqueous Mucin inner

Quantity/Quality

Several layers Lipid outer Aqueous Mucin inner

Quantity/Quality

Tear filmTear film

Causes of Dry EyeCauses of Dry Eye‘Keratoconjunctivitis Sicca’‘Keratoconjunctivitis Sicca’

Causes of Dry EyeCauses of Dry Eye‘Keratoconjunctivitis Sicca’‘Keratoconjunctivitis Sicca’

Lacrimal gland aging

Strongly associated with blepharitis

Inflammatory conditions

Rheumatoid arthritis

Sarcoidosis

Sjogrens Syndrome

Laser refractive surgery

Lacrimal gland aging

Strongly associated with blepharitis

Inflammatory conditions

Rheumatoid arthritis

Sarcoidosis

Sjogrens Syndrome

Laser refractive surgery

Sjogren’s SyndromeSjogren’s SyndromeSjogren’s SyndromeSjogren’s Syndrome

Sjogrens SyndromeSjogrens Syndrome Very severe dry eyes Middle-aged women KCS/Xerostomia and vasculitic disease

Rheumatoid Arthritis SLE Scleroderma Polyarteritis

Blood tests ANA 70% SSA(RO) 70% SSB (LA) 40% RhF 60%

Very severe dry eyes Middle-aged women KCS/Xerostomia and vasculitic disease

Rheumatoid Arthritis SLE Scleroderma Polyarteritis

Blood tests ANA 70% SSA(RO) 70% SSB (LA) 40% RhF 60%

SymptomsSymptoms

Feel dry (Can be watery!)

No relation to emotional tearing

Gritty burning eyes

Worsening through day peak in evening

Worsened by reading, TV, computer

Worsened by air conditioning, central heating, dry

arid conditions

Feel dry (Can be watery!)

No relation to emotional tearing

Gritty burning eyes

Worsening through day peak in evening

Worsened by reading, TV, computer

Worsened by air conditioning, central heating, dry

arid conditions

SignsSigns

Often none!

Poor tear film on SL with rapid break-up time

Punctate staining of cornea inferiorly

Filament strands of mucus on cornea

Schirmers test

Often none!

Poor tear film on SL with rapid break-up time

Punctate staining of cornea inferiorly

Filament strands of mucus on cornea

Schirmers test

SignsSignsRapid tear break-up time

SignsSignsRose Bengal staining

SignsSignsMucus Filaments

Schirmers TestSchirmers Test

Treatment - LifestyleTreatment - LifestyleTreatment - LifestyleTreatment - Lifestyle

Avoid dry situations Car heater Air conditioners Irritants cigarette smoke etc.

Drugs BP, antidepressant, antihistamine etc Increase humidity

Plants, wet towels, radiator trays etc.

Humidity chambers Wraparound glasses Swim goggles

Avoid dry situations Car heater Air conditioners Irritants cigarette smoke etc.

Drugs BP, antidepressant, antihistamine etc Increase humidity

Plants, wet towels, radiator trays etc.

Humidity chambers Wraparound glasses Swim goggles

Treatment-LubricantsTreatment-LubricantsTreatment-LubricantsTreatment-Lubricants

Liquid drops

Frequent application

Gels

More blurring

Ointments

Usually only at night

Nocturnal lagophthalmos

Preservative free?

Liquid drops

Frequent application

Gels

More blurring

Ointments

Usually only at night

Nocturnal lagophthalmos

Preservative free?

Liquid LubricantsLiquid Lubricants

Gel LubricantsGel Lubricants

OintmentsOintments

Other TreatmentsOther Treatments

TreatmentTreatment Anti-inflammatory

Steroid

Cyclosporin –Restasis

Antimucolytic

acetylcysteine –Ilube

Oral pilocarpine-Salagen

Usually only in Sjogrens

Side effects/limited efficacy

Anti-inflammatory

Steroid

Cyclosporin –Restasis

Antimucolytic

acetylcysteine –Ilube

Oral pilocarpine-Salagen

Usually only in Sjogrens

Side effects/limited efficacy

TreatmentTreatment

Punctal occlusion

Cautery

Plastic Plugs

Smartplugs

Punctal occlusion

Cautery

Plastic Plugs

Smartplugs

Punctal CauteryPunctal Cautery

Simple procedure under L/A

Often preceded by temporary trial occlusion

Cautery inserted into punctum/canaliculus

Sometimes not successful

Permanent and difficult to reverse

More common to use temporary plugs first

Simple procedure under L/A

Often preceded by temporary trial occlusion

Cautery inserted into punctum/canaliculus

Sometimes not successful

Permanent and difficult to reverse

More common to use temporary plugs first

Punctal PlugsPunctal PlugsPunctal PlugsPunctal Plugs

SmartplugsSmartplugs

Age-Related CataractAge-Related Cataract

Definition Symptoms Examination Common Clinical Types

DefinitionDefinition

Change in clarity of human lens Commonly an ageing change – a

normal degeneration throughout life ‘Cataract’ – significant effect on vision Often optometrist ‘unable to help with

change of glasses’

SymptomsSymptoms

Rapid change in spectacle prescription – myopic shift

Blurring near and distance Glare No pain, watering, redness

ExaminationExamination

Competent visual acuity Dilating drops

Direct Ophthalmoscope

Common TypesCommon Types

Nuclear sclerosis

Cortical

Posterior Subcapsular

Anatomy

Nuclear

Cortical

PSCLO

Acute Angle ClosureAcute Angle Closure(Glaucoma)(Glaucoma)

Incidence increases with age peak ~70 years 0.1% incidence in UK Effect of cataract

surgery 3/4x commoner in females Associated with hypermetropia (long sight) Normally unilateral

CauseCause Shallow

anterior chamber with narrow angle

Pupil block Angle occlusion

with rapid severe elevation of IOP

SymptomsSymptoms

Intermittent discrete episodes of aching of eye with blurring/halos Semi–dilated pupil dim light Evening onset Goes away after sleep

Full attack Increasing intensity pain - vomiting/distress Progressively severe blurring Will not resolve without treatment

SignsSigns

Red eye circumciliary injection Fixed unreactive semi–dilated oval pupil Hard very tender eye with high IOP