Transcript Slide 1

Jane Goodwin BSc MSc
Nurse Practitioner in Primary Care
and Ophthalmic PwSI (practitioner with
specialist interest)
3.9.08 – GP Registrar
•Requests/concerns – what do you want ?
•Examination – VA
•Case studies
•Examination - Ophthalmoscope
•Case studies
•Other presenting problems
•Questions
Examination
• Visual Acuity
• To asses distant
vision.
• To determine if a
refractive or
pathological disorder.
• Baseline
• Medico/legal
requirement.
Equipment
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Pen Torch
Pin Hole
Snellen Chart
Ophthalmoscope
Fluorescien
Benoxinate
Tropicamide
Your Turn!
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In groups of 3 or 4
3 metres from chart
Measure Va in each eye
See instructions for further reference
Case Studies - One
The opticians letter states
‘this man has a cataract in the left eye and I
have advised him to seek a specialist
opinion’
His VA is 6/9 right and 6/12 left
1. What do you do as a GP?
2. Are there any options?
Two
Ten weeks after uncomplicated cataract
surgery a patients requests a further
prescription of G. Maxidex. He missed
his post operative review.
1. What are you going to do ?
• Commonly used post
op for 3-4 weeks
QDS.
• Is normally stopped at
post op visit.
• Request should be
denied esp if eye
white/asymptomatic.
• Early review at OPA
Three
One year after cataract surgery, a patient
complains of gradual deterioration in
vision, in the operated eye.
1. What is the likely cause?
2. What do you do ?
Four
A 50 year old man notices a single black
object in the field of his left eye. It moves
on eye movements.
1. What is likely cause?
2. What will you do?
3. What features would concern you?
Flashes and Floaters
Decreased Va?
Yes
Continued
NO
Transient
Typically 20 minutes
Duration
-Vitreous Haemorrhage
-Ocular Migraine
-PVD with retinal detachment
-Posterior Uveitis
-PVD
-(+/- retinal hole formation)
Referral Guidelines
Flashing lights and floaters
• Retinal holes and detachments – difficult
to see with ophthalmoscope.
• Hx >6/52 Routine Referral
• Hx < 6/52 esp in under 55’s urgent OPD
referral
• Hx recent onset with decreased VA –
URGENT A/E
Five
A 28 years old female presents with a
smooth, round swelling in Left upper lid.
It has been present for 2 months.
1. What is the likely diagnosis?
2. What do you do?
• Stye (abscess
formation at root of
lash)
• Meibomium cyst
(Chalazion)
• Orbital cellulitis
• Preseptal
cellulitis
Six
A 20 year old women presents with bilateral
red eyes that are gritty and burning.
Discharge is evident on the lashes.
1. What is the likely diagnosis ?
2. What else could it be?
• Vernal
Conjunctivitis
• Chemosis Conjunctival swelling
from allergy and
excessive rubbing
• Oil secretion
from
Meibomian
Glands
• Blepharitis
Lid Hygiene
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150ml Cooled boiled water
1 tea spoon Baby shampoo
Mix and store in fridge up to 1/52
Using cotton bud – clean top and bottom
lashes (as if putting on eye liner)
• Daily for 2/52 then decrease to twice a
week indefinitely
Seven
A 24 year old man presents with a painful
left red eye that has been present for 5
days and has been getting worse every
day. He is quite photophobic.
1. What do you do ?
2. What conditions do you consider ?
• Episcleritis
• Scleritis
• Dendritic Ulcer
• Anterior Uveitis (Iritis)
Eight
An 80 year old women complains of a very
painful eye along with a feeling of
nausea of 2 days duration. On
examination the eye is red.
1. What condition do you want to exclude ?
2. How do you do this ?
• Acute Angle
Closure
Glaucoma
• Digital Tonometry
Coffee Time !
Nine
A 75 year man complains of sudden loss of
vision in one eye. Visual acuity is ‘hand
movements’ only.
1. What are the likely causes?
2. What condition do you especially want to
exclude ?
3. How do you do this ?
Central Retinal Artery Occlusion
• Milky white Retina
with Cherry Red
spot at the macula.
• Can present with
sudden loss of
vision or have
transient vision
loss a few days
before.
Central Retinal Vein Occlusion
• Central vein which drains
blood from the retina
becomes blocked,
causing a back flow of
blood, hence the vessels
leaking into the retina
causing swelling.
• Ischemic causes of a
blockage increases
complications. Abnormal
growth of blood vessels
occur.
• Some can be treated with
Laser
Optic Neuritis/Papilloedema
Examination of Fundus
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Requires practice and confidence.
More accurate with dilated pupil.
Knowledge of A&P to interpret findings.
Limited view with direct ophthalmoscope.
RAPD
(relative, afferent, pupillary, defect)
• RAPD is testing the nerve pathways to the brain.
Inflammation, damage, or pressure on the
nerves will cause a defect.
• Light shone into a healthy eye causes
constriction in both eyes. Swing light to other
healthy eye and same reaction will occur.
Repeat 3 or 4 times.
• In a damaged eye – on swinging light to
damaged eye neither pupil will constrict and
damaged eye will start to dilate.
Ophthalmoscope Practice
• Find tops tips for using ophthalmoscope in
hand out
• Get into small groups
• Practice !!!!!
Ten
A 60 year lady complains of recent onset of
distorted and blurred vision especially
when reading the newspaper.
1. What eye conditions do you suspect?
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Age related Macular degeneration
Cataracts
Diabetic Retinopathy
Hypertension
ARMD – wet & dry
• Dry – 80% (however, 1 in 10 patients will
develop wet)
• Cells under the macular break down &
cause drusen (yellow deposits) under the
retina.
• Signs – print is blurred, colours are dull,
vision can be hazy and central vision is
affected
WET
• Abnormal growth of blood vessels that
leak blood and fluid.
• Causes scarring& permanent loss of
central vision
• Signs – lines becomes wavy, door frames
appear wonky.
• Onset is usually rapid.
• Early diagnosis is critical if sight is to be
saved
Risk Factors
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Increases with age
Fhx / genetics
Gender – more common in females
Smoking
Obesity
Poor nutrition – enc colourful veg
CVD
Caucasian
Treatment
• Lucentis and Macugen – blocks abnormal
vessel growth and leakage and targets
proteins that are thought to cause ARMD.
• Intravitreal injections every 6 weeks 9
times a year.
• Post Rx – redness, specks in vision, Abx
are commonly prescribed & monitor with
amsler chart
Brief look at other conditions
Diabetic Retinopathy
• Known as Background or
Non-proliferative
• Hard exudates – yellow
flecks deep in the retina
reflecting leakage of
incompetent pre capillary
retinal arterioles
• Haemorrhages – ‘red
dots’ show mini blow outs
of the diseased pre
capillary arterioles
Proliferative
• This shows the tangling
of blood vessels at the
optic disc & nearby retina.
• The vessels are weak
walled & break easily.
They bleed into the retina
& vitreous jelly & can
cause retinal detachment
& blindness.
• Treatment with argon
laser is helpful
Glaucoma
Cupped disc
Normal disc
• As a rule optic disc
assessment is difficult as
there is an infinite variety
of normal optic discs.
• The main visible sign is
thinning of the
neuroretinal rim causing a
larger central cup. As the
disease progresses the
rim is eroded until there is
little or no rim left.
Disc Oedema with Hypertension
• Disc oedema with
splinter
haemorrhages
• Caused from severe
hypertension
Guess the condition
• Basal cell
Carcinoma
• Papilloma
• (removed for cosmetic
purposes)
• Cyst of Moll
• Cyst of Zeis
• Pinguecula
• Pterygium
• Entropian
• Ectropian
• Xanthelasma
• Milia
• Corneal
Foreign Body
• Rust Ring
• Pigmented
Lesion
• Conjunctival
Melanoma
Paediatric ophthalmology
• Development of eyes reaches full maturity
at 7 years of age.
• At birth an inborn reflex normally brings
the image of an object onto the foveae of
both eyes. Over time continual practice of
this reflex is cemented into the ability to
perceive depth.
• This can break down in two situations……
What are they?
1.
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If one eye has poor vision - eg
Congenital Cataract
High refractive error
Ptosis – drooping eye lid
Other pathology such as retinoblastoma
2. The other if one eye is squinting
Squint
• Brain ignores the image from poor eye and concentrates on the
good eye.
• The poor eye turns in (convergent squint) and to avoid double vision
the brain suppresses the image from this eye.
• If not corrected early, the eye does not develop hence the vision
remains poor for life.
Final Question
Mother with 3 year old child presents saying
she has noticed the Childs eye turning
inwards.
O/E - you did not find any evidence of a
squint
What do you do?
What you need to know!
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Diagnostic drops to have in your surgery
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Benoxinate – anaesthetic – last for 20 mins great for FB removal.
Fluorescein – orange dye for ocular surface problems
Tropicamide – if need a clearer of view of fundus
Glaucoma drops – check for bradycardia, and SOB. Most can be prescribed in packs
of 3 – this is cheaper to prescribe and convenient for pt.
Prostaglandin drops used in glaucoma eg Latanoprost cause eye lash growth,
change in iris pigment and discolouration of skin under lower lid.
Corticosteroid drops – never prescribe unless undergoing regular monitoring at local
eye unit
Artificial Tear drops / ointment – there are loads – start with hypromellose, then
progress to gel tears and lacri-lube at night
Antiviral ointment – I doubt you’ll prescribe without confirmation of herpetic infection
Antibiotic ointment / drops – next slide
Chloramphenicol
• Ointment 1% - QDS
• Drops 0.5% - QDS
– Abraisions
– Dry eye syndrome
– Soften FB or rust ring
– Bacterial infection
– No blurring of Va
– To be stored in fridge
– Easier to apply if tube
warmed in
hand/pocket.
– Size of grain of rice
– DO not use in SOFT
contact lens use.
– Asses if can instil
drops
Fucithalmic
• Gel / drops 1%
• BD use as long acting 12hrs (no benefit
using more frequently).
• Can sting for 10 secs on instillation.
• More convenient to use.
Chloramphenicol v Fusidic
Mini Review
Reference
• Griffiths P (2003) What type of eye drops
should be given to a toddler with
conjunctivitis? British Journal of
Community Nursing, Vol 8 No 8 pg 364
Local Services to Epsom
• Surrey Association for Visual Impairment
(SAVI)
• www.surreywebsight.org.uk Tel
0127664631
• Epsom and Ewell Club for the blind
• Tel 01372 723057
• Swail House – Ashley Rd - Housing for
visually impaired -
Questions
The End
References
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BNF 46 (2003) September
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Galbraith A et al (1999) Fundamentals of pharmacology, A text for nurses and health
professionals. Addison Wesley Longman Ltd.
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Gregory R (1998) Eye and Brain, The Psychology of Seeing, 5th Ed Oxford University Press,
Oxford.
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Griffiths P (2003) What type of eye drops should be given to a toddler with conjunctivitis? British
Journal of Community Nursing, Vol 8 No 8 pg 364.
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Kanski J (1999) Clinical Ophthalmology, Butterworth-Heinemann, Oxford.
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Maclean H (2002) The Eye in Primary Care , Butterworth-Heinemann, Oxford.
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Pavan-Langston D (1996) Manual of Ocular Diagnosis and Therapy, 4th Ed, Little Brown and
Company, Boston.
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Stein H (1992) Ophthalmic Terminology, 3rd Ed Mosy Year book, London.
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Stollery R (1997) Ophthalmic Nursing, 2nd Ed, Blackwell Science.