BMEC A&E and Urgent Care Clinic Mr. K.S. Lett Consultant Ophthalmologist Clinical Lead for Emergency Eye Service And Vitreo-Retinal Service Overview ● Primary care services @ BMEC ● Differentiating emergency, urgent and routine referrals ● Differentiating timing of urgent and routine cases ● Identify what emergency management can be instigated by optometrist ● Update access pathways and contact numbers BMEC A&E ● 2nd biggest & busiest Eye Cas in UK ● Covers Birmingham, Solihull, Sandwell, Dudley, Worcester, Redditch ● Covers further afield for some conditions ● Walk ins and referrals ● Open 08.30 – 19.00 (Sunday 18.00) ● OOH City Hospital main A&E Consultant Led Service Session Mon Tue Wed Thu Fri

am Pandey Ghosh Lett Aralikatti Chavan Plastics VR MR

pm Damato, Mellington Mitra Nessim El-Defrawy Das Plastics VR Glaucoma Paeds Other Medical Staff ● Specialty doctors ● Subspecialist Fellows, junior & senior ● Vitreo-retinal ● Corneal ● Glaucoma ● Neuro- ● ● Medical ● OSTs (ST 1-7) daytime ● On-call (1st, 2nd, 3rd, 4th) Nursing Staff ● Alison Hynes, Sister in Charge ● Advanced nurse practitioners ● Staff nurses ● HCAs

● Clerical staff Services Provided ● Assessment of all eye accidents & emergencies ● Urgent treatment – medical, laser, surgical ● Urgent Care Clinics Mon – Fri, 09.00 – 19.00 ● Training ● Specialist doctors, GP registrars ● Nurses, Optometrists, Orthoptists ● Medical students Pre-Triage System ● Red Need to be seen within a few hrs, further triaging. ● Amber Need to be seen within 72 hrs, diverted to UCC slots. ● Green No need for urgent assessment, referred to GP, optometrist or to OPD (via GP). Red – Very Urgent ● Penetrating eye injury ● Acute post-op ● Severe chemical injury ● GCA with visual symptoms ● Sudden loss of vision <6hrs Red - Urgent ● Orbital cellulitis ● Painful with visual loss ● with good VA ● , esp. with CL wear ● Blunt trauma with hyphaema & ↑ IOP ● Corneal graft rejection ● Painful Amber ● Flashes & , no loss of vision ● Red eye without severe or visual loss ● Retinal vein occlusions (OPD 4-6/52) ● Diabetic with vitreous haemorrhage ● Wet AMD (preferably refer to Fast Track Macular Clinic) Green – GP Mx ● Bacterial & viral ● ● ● Dry eyes ● Lid lumps and bumps Green – OPD Referral ● ● Chronic / gradual visual loss (months) ● Open angle glaucoma, ● Watery eyes ● , ● Lid lumps & bumps ● Non-acute diplopia Trauma ● Burns ● Acid, alkali, thermal, arc eye ● Abrasions & lacerations ● Lid, corneal and conjunctival, PEIs ● Foreign bodies ● Corneal, conjunctival, sub-tarsal, intra-ocular ● Blunt trauma ● SCH, hyphaema, choroidal rupture ● OBF, TON Chemical Injury Potential emergency

Alkali or Acid pH check

Immediate irrigation

May result in limbal stem cell failure Corneal Abrasion History provides indication of severity

Doesn’t always require A & E

Oc. Chlor qid 5/7 Lid Laceration Refer to A & E

Be mindful of additional injuries Foreign Bodies Can be removed by optoms if confident g. Chlor qid 5/7

Refer if unable to remove or rust rings

Always check for subtarsal FB as well Penetrating Eye Injury Beware of intra-ocular FB

Don’t put pressure on Intraocular Foreign Body Detailed history

Determine composition of IOFB

Influences urgency of surgery Sub-conjunctival Haemorrhage Spotaneous vs traumatic

Self limiting

No treatment

No referral required Hyphaema Check IOP

Risk of rebleed

Risk of endothelial staining Blow Out Fracture Assess for globe damage, TON

Orbital surgery only if tissue entrapment

Normally done within 4/52 Angle Recession Risk of glaucoma with increasing degree of recession

Optometry monitoring Risk of glaucoma

Phacodonesis

Difficult surgical repair Cornea ● Dry eye ● Recurrent erosion syndrome ● ● Ulcers ● CL related ● Acanthamoeba ● Dendritic ● Shingles Dry Eye Lubricants

Look for blepharitis

Refer if unable to improve symptoms Recurrent Corneal Erosion Index injury

Typically pain on waking / opening eyes

Oc. Simple / Lacrilube nocte 3/12

Refer if no improvement Pterygium Only require surgery if threatening visual axis

Lubricants

Routine referral Bacterial Esp in CL wearers

Excess wear, poor hygiene

Urgent referral

Differentiate from marginal keratitis Acanthamoeba Esp in CL wearers

Hx of swimming, showering in lenses

Non healing epithelial defect

Pain disproportionate to signs

Urgent referral Dendritic Ulcer Typically HSV 1, as with cold sores

Self limiting

Treated with topical Acyclovir / Valgancyclovir

UCC referral Herpes Zoster Ophthalmicus Oral antiviral Rx if started within 48hrs onset of rash – by GP

Not always eye involvement

Hutchinson’s sign 70% chance eye involvement

Most eye involvement doesn’t require specialist Rx ● Conjunctivitis ● Bacterial, viral, allergic ● ● Bacterial Conjunctivitis Purulent / mucopurulent discharge

Self limiting g. Chlor qid 1/52

No referral required Viral Conjunctivitis Self limiting

Watery discharge

Follicular reaction

No referral required unless corneal involvement Allergic Conjunctivitis Identification and avoidance of trigger allergen

Topical Sodium cromoglycate

Oral anti-histamines

No referral required unless persistent problem Episcleritis Self limiting

Mild – Moderate discomfort

Oral NSAIDs, eg ibuprofen

No referral required unless persistence

Steroid dependency Scleritis Severe dull boring pain

Strong association with auto- immune and connective tissue disease

Urgent referral

Needs extensive management Lids ● Blepharitis ● Anterior, posterior ● , stye ● Ectropion, entropion ● Pre-septal Anterior & Posterior Blepharitis Lid hygiene

Hot compresses

Treat associated dry eye

No referral required Chalazion Hot compresses

GP to prescribe Abx if infected

No referral to A & E Senile Ectropion & Entropion Ensure lubrication of ocular surface

No acute management in A & E

GP to refer routinely Pre-Septal Cellulitis Need to differentiate with

Pt not systemically unwell

No orbital signs

Needs oral Abx (GP)

Refer urgently if in doubt Orbital Cellulitis Potentially sight / life threatening condition

Emergency referral

Pt systemically unwell, pyrexial

Orbital signs

Need admission and IV ABx Neuro-ophthalmology ● IIIrd, IVth, VIth nerve palsies ● ● Papilloedema ● ● Giant cell arteritis 3rd, 4th, 6th Palsy Majority will be microvascular in elderly diabetic hypertensive population

If so, routine referral

Beware of painful nerve palsy esp 3rd PCA aneurysm

Beware of assoc headache esp 6th GCA Optic Neuritis, Papilloedema Unilateral vs bilateral

Disc haemorrhages

Both may require urgent referral (depending on duration of symptoms) Anisocoria In light, larger abnormal

In dark, smaller pupil abnormal

Ask if noticed before – old photos, friends and family

Urgency of referral depends on duration Giant Cell Arteritis Temporal headache and tenderness

Blurred vision

Polymyalgia

Associated with RAOs

Emergency referral to Eye Cas ONLY if visual symptoms eg. Amaurosis

Otherwise GP to refer urgently to Rheumatology / Physicians Glaucoma ● AACG ● Neovascular ● What IOP is urgent? ● <35mmHg refer to outpatients ● >35mmHg refer to UCC / Eye Cas Acute Angle Closure Glaucoma Typically presents midday onwards

Fixed, semi-dilated pupil

High pressure, corneal oedema

Closed angle – may need to examine fellow eye

Emergency referral

Needs medical treatment then laser PI

More extensive surgery may be necessary rubeosis Due to ocular ischaemia

Can be confused with dilated vessels in uveitis

Needs UCC referral

Likely to need pan retinal photocoagulation Uveitis ● Anterior ● Intermediate ● Posterior ● Posner Schlossman ● Mild uveitis ● ↑IOP ● Pain Anterior Uveitis Cells, flare, KPs, PS

Frequently recurrent cases

Need UCC referral unless severe case, raised IOP, fibrin Intermediate & Posterior Uveitis Intermediate often chronic Hx of floaters

No retinal involvement

If no reduction of acuity, routine referral

Posterior normally severe rapid loss of vision.

Retinal involvement

Needs urgent referral Vitreo-Retina ● PVD ● Vitreous haemorrhage ● Retinal tears and holes ● Retinal detachment ● ● & macular hole ● Dry & Wet AMD ● Vascular occlusions ● Proliferative ● Central serous retinopathy Posterior Vitreous Detachment Only 30-50% PVD symptomatic

Look for tobacco dust

Ensure not red blood cells

Symptomatic PVD refer to UCC, depending on duration

If tobacco dust refer to Eye Cas Vitreous Haemorrhage Check for systemic associations eg. DM, HT, Sickle

Examine fellow eye

If present, UCC referral (duration dependent)

In absence of systemic disease, PVD with VH has 80% incidence of retinal tear

Urgent referral to Eye Cas Retinal Breaks

Horseshoe tears, U-tears

Arrowhead tears

Operculae

Atrophic holes

Giant retinal tears

Dialysis Lattice Degeneration Population incidence 10-15%

Frequently seen with holes

If asymptomatic, routine referral

In vast majority of cases, no prophylactic treatment Retinal Detachment Is the macula on or off? VA Clinical exam OCT

If on, emergency referral

If off, Eye Cas, UCC or clinic depending on duration

Check for symptoms, signs of chronicity

NOT ALL DETACHMENTS ARE AN EMERGENCY!

Retinoschisis Typically asymptomatic

Immobile thin transparent retina

No breaks

Inner & or outer leaf breaks

Frequently mirrored in fellow eye

Routine clinic referral AMD Dry vs Wet

No referral for dry – monitoring

Wet refer via fast track system – no need to send to Eye Cas / UCC Epiretinal Membrane Insidious onset

Only treatment is surgery

Routine referral Macular Hole Often present for considerable period of time before diagnosis

Only treatment is surgery or in small number of cases, ocriplasmin

Routine referral Retinal Vein Occlusion No emergency treatment available

Refer via fast track system

Need long term treatment Retinal Artery Occlusion Irreversible retinal damage from 4hrs of onset

Immediate emergency treatment tried up to 8hrs from onset Aspirin ocular massage rebreathing into bag

Beyond this time no heroic measures

Check for GCA symptoms

TIA referral from GP / UCC Neovascular Retinopathy Most commonly diabetics

Also Sickle, prior RVOs and rarely RAOs

Refer to UCC unless also VH Central Serous Retinopathy Typically young – middle aged men

Type A personalities

Stress

Self limiting <6/12

Treatment only if not resolving

Routine referral Contact Numbers ● Triage nurse 0121 507 6780 ● Fax 0121 507 6773 / 6711

● Fast Track Macular / RVO 0121 507 6714 ● Fax 0121 507 6726

● BMEC switchboard 0121 554 3801

Any Questions? Thank you