Idiot’s guide to eye problems

Cass Adamson

January 2011

What do GPs need to know?

• Many conditions

• Wealth of info

• GP books short chapters

• Serious consequences if wrong

Take home message:

• If in doubt – REFER!!!

Session plan:

• Presentation on assessing and managing common or serious eye problems

• Videos on eye examinations (optional)

• Practical session for practising fundoscopy and other eye examinations

• CSA practise

Eye assessment

• External examination of eyes and face

• Visual acuity

• Visual fields

• Pupils + swinging torch test

• Fundoscopy

• Eye movements

“There’s something in my eye”

• Joan Peters 65

• Controlled hypertension

• 5/7 ago sudden appearance of ‘tadpole’ in L eye with some flashing lights.

• No trauma

• Vision NAD

• BP 148/79

• Eyes appear normal

• PEARL

• Eye movements NAD

• Fields NAD

• VA (with glasses)

R – 6/5

L – 6/6

Fundoscopy:

What do you do?

a)Reassure herb)Advise optician r/vc)Ask about foreign travel and explain that

the ‘tadpole’ could be a wormd)Refer routinelye)Refer urgentlyf) Refer immediately

• Posterior vitreous detachment

- normal examination

- Floater black ‘cobweb’ or ‘curtain’

• But new flashes and floaters are retinal detachment or retinal tears until proven otherwise.

→ refer urgently

Retinal detachment

• Rhegmatogenous or traction.• Flashes, floaters and field loss – curtain from periphery• Blurred central vision

Retinal tear Vitreous haemorrhage

• Flashes and floaters• Floaters large and red

or black

• Tearing or bleeding• Floating blobs or

severe visual loss

“It’s double vision, Doc”

• Hanif Khan 47

• Occasional headaches

• Last night sudden onset diplopia and a headache which is worsening.

• Taken some ibuprofen, partial relief

• L eye looking down and outwards

• Unable to look up, down or medially

• Partial ptosis• L pupil slightly

dilated and less reactive to light

What do you do?

a) Inform him it is a CN III palsy and to come back if his symptoms worsen

b) Prescribe analgesia for headache

c) Ask optician to examine fundi then r/v patient

d) Refer routinely

e) Refer urgently

f) Refer immediately

• New sudden onset diplopia adult has a life threatening cause eg aneurysm until proven otherwise → immediate referral

• Gradual onset diplopia in adult can be tumour.

• Can see transient or persisting diplopia with temporal arteritis

Causes of diplopia:

• Intoxication• Head injury• CVA• Orbital floor #• Guillain-Barre• Myasthenia gravis• Early cataract • CN III, IV, VI palsies

• Other signs to look for:

• Enlarged pupil, ↓ response light – CN III palsy

• Ptosis – CN III palsy or MG• Lid retraction – thyroid eye

disease• Red eye – thyroid eye disease

or orbital inflammation • Ocular torticollis – CN IV palsy

Blurred vision:• Serious eye/brain

disease likely if symptoms:

- Unexplained eye pain- Photophobia- Distortion vision- Flashes of light- New floaters- Loss part visual field- Sx temporal arteritis

• Serious eye/brain disease likely if signs:

- Red eye- Visual field defect- RAPD- Abnormal cornea, iris

or pupil- Loss red reflex- Optic disc swelling or

pallor

“ I can’t see in my left eye!”

• Hannah Cook 76

• Type 2 diabetes and hypertension

• This morning sudden reduced vision L eye

• Mildly painful

• DH: bendroflumethiazide, metformin, simvastatin and aspirin

• BP 156/66• Last HbA1c 7.9%• VA (with glasses)

R – 6/9

L – 6/18• Eye movements NAD• Possible RAPD

• Fundoscopy:

What is it?

What do you do?

a) Review her medications and add in a further agent for BP and DM

b) Make sure she sees her optician soon as her glasses are clearly inadequate

c) Refer routinely

d) Refer urgently

e) Refer immediately

Proliferative Diabetic Retinopathy:• Cotton wool spots• Hard exudates• Dot and flame haemorrhages

Central retinal vein occlusion:• Widespread retinal haemorrhage • Tortuous dilated veins• Macular oedema • Optic disc swelling • +/- cotton wool spots.

• Branch retinal vein occlusion:

• Appearance similar to CRVO

• Sx: sudden blurring or field defect

• Central retinal artery occlusion:

• Sudden painless loss all vision

• ↓↓↓ VA (light only), RAPD

• Pale retina, cherry red macula

Transient visual loss:

One eye or both?

Amaurosis fugax-Carotid stenosis

- Temporal arteritisTransient obscurations

-Papilloedema-Orbital tumour

Migraine

Vertebrobasilar TIA

Papilloedema

Occipital tumour

ONE BOTH

Sudden or rapid visual loss:

One or both?

RAPD and/orField loss?

Bilateral acute optic neuropathy

Acute retinal detachmentMajor retinal vascular occlusion

Acute optic neuropathyOther acute retinal disease

Minor retinal vascular occlusion‘wet’ ARMD

Vitreous haemorrhageOther macular or retinal disease

ONE BOTH

YES NO

Gradual visual loss:

RAPD and/or field loss present?

Slowly progressive optic neuropathyAdvanced chronic glaucomaChronic retinal detachment

Cataracts‘dry’ ARMD

Diabetic maculopathyOther macular disease

YES NO

“My eyes keep going funny”

• Jemima Duck 26

• Had headache past 3/52. 4/7 when bending forwards nausea and transient visual loss

• BMI 29.6

• Takes COCP

• No PMH

• ?RAPD (subtle)• Eye movements NAD• VA

L - 6/9

R – 6/12• Fields - ?central

scotoma

• Fundoscopy (bilateral):

What do you do?

a) Refer for routine CT/MRI head

b) Refer for urgent CT/MRI head

c) Call 999

d) Admit medical team

e) Refer to ophthalmology routinely

f) Refer to ophthalmology urgently

Papilloedema:

• Unilateral – disease within eye

• Bilateral - ↑ICP

“My eye is droopy”

• Bob Smith 54 year old smoker.

• 5/7 drooping L eyelid, worsening

• Otherwise asymptomatic

• Possibly some weight loss

• Longstanding mild dry cough

Probable Pancoast’s Syndrome

• Other causes:• Head or neck trauma• Brainstem stroke• Dissecting internal

carotid aneurysm

Approach to ptosis:

• Bilateral: age related or MG• Mild: Horner’s syndrome• Double vision or limited eye movements:

MG or CN III palsy• Pupil small: Horner’s• Pupil large: CN III palsy• Fatigability: MG

→refer

“My eye looks odd”

• Sarah Brown 19yr.

• Her mother noticed her R eye looked ‘odd’ this morning.

• Recent bad cold.

• No PMH

• Takes COCP

• Adie’s pupil• Unilateral dilated pupil• Poor or no response light.

Unequal pupils:Do pupils constrict normally to light?

Smaller pupil abnormal

Larger pupil abnormal

Mild ptosis same side?

Ptosis same side, Double vision orAbnormal eye movements?

Possible Horner’s syndrome

Possible anisocoria

Likely partial CN III palsy

Adie’s pupilPrevious iris trauma or disease

Dilating substance

YES NO

YES YES

NO NO

More words of wisdom:

• Not all flashing lights with headache are migraine

• Blurred vision or headache needs field test

• Field loss always needs assessment

• Sudden onset visual distortion – urgent ref

• Consider temporal arteritis every pt >50 with headache or visual change

• Red eye with decreased vision, pain or photophobia needs same day referral.

• Any child with a turned eye has sight/life threatening condition unless disproved

• New onset flashes and floaters are retinal detachment until proven otherwise

References:

1. Pulse Plus – Ophthalmology2. Pulse – Picture quiz: Acute Referrals to

Ophthalmology3. Practical Ophthalmology – A Survival Guide

for Doctors and Optometrists (2005). A. Pane and P. Simcock

4. Symptom Sorter 4th ed (2010). K. Hopcroft and V. Forte

5. The 10-Minute Clinical Assessment (2010). K. Schroeder

6. Google images!

Funsdoscopy:

• http://www.heine.com/eng/INFO-CENTER/INFORMATION-LITERATURE/Filme-und-Neuheiten/Direct-Ophthalmoscopie