practical ophthalmology for gps: glaucoma mr kuang hu ma mb bchir phd (cantab) frcophth consultant...

Practical Ophthalmology for GPs: Glaucoma

Mr Kuang HuMA MB BChir PhD (Cantab) FRCOphthConsultant Ophthalmic Surgeon

9 October 2014

www.moorfields.nhs.uk

• What is glaucoma?• Management of glaucoma• Differential diagnosis of acute glaucoma• Referral pathways

Glaucoma


Blinding

•2nd biggest cause of blindness worldwide•Functional deficit, handicap, disabilityCommon

•Affects more than 1 in 100 of 40+ years old

•10% of Croydon patients have it, or are at risk

What is Glaucoma?


People don’t notice until it’s too late

•Visual loss is painless and progressive

•Exception is acute glaucoma

What is Glaucoma?


What is Glaucoma?

Group of diseases with common features:

• Eye pressure is too high

• Damage to the optic nerve

• Damage to vision

• Treatment is to lower eye pressure


What is Glaucoma?Spectrum of damage to vision

• Mild: minimal visual lossno handicap or disability

• Severe: tunnel visiontrips, can’t drive

• End stage: ‘blind’can’t read, can’t see TV


Acute rapid rise in pressure

Chronicgradual rise in pressure

Two types of glaucoma


HistoryHistory HoursHours Severe painSevere pain NauseaNausea

ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Hazy CorneaHazy Cornea Rock hard eyeRock hard eye

Acute glaucomaAcute glaucoma

Refer immediatelyRefer immediately


Chronic glaucomaPainless

Gradual loss of vision

White eye

Previous diagnosis

Already on drops

Management of Management of GlaucomaGlaucoma

IdentifyIdentify Acute glaucoma: 1 case every 3-10 yearsAcute glaucoma: 1 case every 3-10 years Definite chronic glaucomaDefinite chronic glaucoma Possible chronic glaucoma – ‘suspects’Possible chronic glaucoma – ‘suspects’ High risk of chronic glaucoma – raised pressureHigh risk of chronic glaucoma – raised pressure


IdentifyIdentify Pressure measurementPressure measurement PachymetryPachymetry GonioscopyGonioscopy Visual field testVisual field test Slit-lamp stereoscopic examination of optic discSlit-lamp stereoscopic examination of optic disc Imaging of optic discImaging of optic disc

TreatTreat Lower eye pressureLower eye pressure Prevent further damage to optic nervePrevent further damage to optic nerve Prevent progression of visual lossPrevent progression of visual loss Prevent disability and handicapPrevent disability and handicap

MedicationsMedications

LaserLaser

SurgerySurgery



Management of GlaucomaMedication• Eye drops (5 classes)• Oral, intravenous

Laser• Selective laser trabeculoplasty• YAG laser iridotomy• Argon laser iridoplasty• Diode laser cycloablation

Surgery• Minimally-invasive, eg Trabectome (NICE)• Lens extraction• Trabeculectomy with cytotoxic antiscarring agents• Aqueous shunt ‘tube’ surgery (several types)


Management of Glaucoma

Two basic types



Two basic types

Chronic

• Gradual rise in pressure

• Painless

• White eye

• Gradual visual loss

• Treatment with drops



Two basic types

Chronic

• Gradual rise in pressure

• Painless

• White eye

• Gradual visual loss

• Treatment with drops

• Please prescribe drops



Two basic types

Chronic Acute

• Gradual rise in pressure • Sudden rise in pressure

• Painless • Acutely painful

• White eye • Red eye

• Gradual visual loss • Rapid visual loss

• Treatment with drops • Drops, IV drugs, laser

• Please prescribe drops



Two basic types

Chronic Acute

• Gradual rise in pressure • Sudden rise in pressure

• Painless • Acutely painful

• White eye • Red eye

• Gradual visual loss • Rapid visual loss

• Treatment with drops • Drops, IV drugs, laser

• Please prescribe drops • Recognize and refer as EMERGENCY


Acute Glaucoma?


Differential Diagnosis of Acute Glaucoma

•Infective conjunctivitis

•Subconjunctival haemorrhage

•Iritis

•Acute glaucoma•Endophthalmitis

•Orbital cellulitis


1-minute ophthalmic assessmentHistory• Acute or chronic• Severity of pain• Other symptoms, past ophthalmic history

Examination• Acuity• Lids• Conjunctiva• Cornea• If possible: Pupils, pressure


HistoryHistory SpontaneousSpontaneous Mild painMild pain Mild blurringMild blurring

ExaminationExamination Looks like bloodLooks like blood

1-minute ophthalmic assessmentSubconjunctival haemSubconjunctival haem

Conservative: BP, INRConservative: BP, INRRefer if not resolvingRefer if not resolving


HistoryHistory DaysDays Mild painMild pain Sticky dischargeSticky discharge

ExaminationExamination Mild blurringMild blurring Mild swelling lidsMild swelling lids Red conjunctivaRed conjunctiva Clear corneaClear cornea Normal pupilsNormal pupils

1-minute ophthalmic assessmentConjunctivitisConjunctivitis

Chloramphenicol eye drops Chloramphenicol eye drops QDS for 1 weekQDS for 1 week


HistoryHistory Days or weeksDays or weeks Moderate painModerate pain PhotophobiaPhotophobia

ExaminationExamination Moderate blurringModerate blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Clear corneaClear cornea Unreactive pupilUnreactive pupil

1-minute ophthalmic assessmentIritisIritis

Refer within 24 hoursRefer within 24 hours


HistoryHistory HoursHours Severe painSevere pain NauseaNausea

ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Hazy corneaHazy cornea Rock hard eyeRock hard eye

1-minute ophthalmic assessmentAcute glaucomaAcute glaucoma



HistoryHistory HoursHours Severe painSevere pain Recent surgeryRecent surgery

ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Normal CorneaNormal Cornea HypopyonHypopyon

1-minute ophthalmic assessmentEndophthalmitisEndophthalmitis



HistoryHistory Severe painSevere pain Loss of visionLoss of vision Double visionDouble vision

ExaminationExamination Loss of visionLoss of vision Unreactive pupilUnreactive pupil Reduced motilityReduced motility ProptosisProptosis

1-minute ophthalmic assessmentOrbital cellulitisOrbital cellulitis



Differential diagnosis of Acute Glaucoma

Use the 1-minute ophthalmic assessmentDiagnosis Management•Subconjunctival haem Conservative•Conjunctivitis Chloramphenicol•Iritis Refer within 24 hrs•Acute glaucoma Refer immediately•Endophthalmitis Refer immediately•Orbital cellulitis Refer immediately


Referral pathwaysUrgent = Telephone 020 8401 3486

Routine = Referral letter


Summary

Glaucoma is a sight-threatening disease

Acute glaucoma is rare, but has common mimics

Chronic glaucoma is common

Identifying chronic glaucoma requires many tests

Treatment is by lowering eye pressure

Moorfields is here to help

Practical Ophthalmology for GPs: Glaucoma

Mr Kuang HuMA MB BChir PhD (Cantab) FRCOphthConsultant Ophthalmic Surgeon

9 October 2014

practical ophthalmology for gps: glaucoma mr kuang hu ma mb bchir phd (cantab) frcophth consultant...

Documents

types of glaucoma slide

drops slide

tv slide

lower eye pressure slide

years acute glaucoma

pressure chronicgradual

optic nerve damage

disability severe