WhenWhen toto CareCare –– WhenWhen toto ReferRefer AcuteAcute EyeEye ProblemsProblems inin thethe CommunityCommunity FrankFrank MunroMunro TodayToday’’ss TalkTalk n Acute Eye Problems n Burden of Disease – Making a Difference n Shifting the Balance of Care? n What do I do now – Could I do more? n Clinical Decisions Making - When to Care – When to Refer ClinicalClinical decisiondecision MakingMaking n DiagnosisDiagnosis n ManagementManagement n DemonstrateDemonstrate CompetenceCompetence n WorkingWorking withinwithin scopescope ofof practicepractice n DODO NONO HARM!HARM! Death Birth TheThe Challenge!Challenge! ScopeScope ofof PracticePractice Chalazia Sub tarsal fb Viral Conjunctivitis Viral ‘Wet’ ARMD Cornea Ping / Pterygium Scleritis Corneal Erosion Marginal Keratitis Uveitis Allergic/Toxic Conjunctivitis Kerataconus int/post Corneal FB Penetrating Corneal Abrasion UV Burn Glaucoma Injury Bacterial Retinoschissis Microbial Keratitis Dry Eye Inclusion conjunctivitis Inclusion Episcleritis Endophthalmitis WhereWhere amam I?I? Cellulitis Ant / Post Blepharitis PVD Corneal Retinal Dystrophy Detachment Conjunctival Hge Keratitis/ Keratopathy Chemical Burns Anterior Cataract Anterior Neoplasia Trichiasis /Epilation Uveitis Ischaemic Optic Dry ARMD Dry ARMD Neuropathy ENTRY ADVANCED EXPERT HES GIES Patient Categories Category No % Category No % Category No % NAD 112 9.6 Blepharitis 39 3.4 Ocular 16 1.4 Anterior Dry Eye 111 9.6 Glaucoma 37 3.2 uveitis 15 1.3 Conjunctivitis 90 7.8 Retinal 35 3.0 Floaters 14 1.2 Diabetes 72 6.2 Tear duct etc 31 2.7 Cyst 12 1.0 Cataract 68 5.9 Episcleritis 29 2.5 Eyelashes 9 0.8 Vitreo-ret 52 4.5 Keratitis 22 1.9 Others 225 19.4 Corneal/Ulcer 48 4.1 Visual disturbance 20 1.7 PVD 44 3.8 Macular 17 1.5 Headache/migraine 43 3.7 Ocular 16 1.4 Total 1161 100 GrampianGrampian WalkWalk--InIn CasualtyCasualty 11 5 1 6 5 1 AAU ACG 121 2 2 10 AION ALLER 1 1 2 ARMD BELL'S 6 BLEPH BLOW # 17 15 15 C CYST C ULCER 1 1 CAT CHE INJ 2 1 3 CL KERA CNOTWT 1 20 CO ABRA CONJ 2 12 CSR DRY EYE 4 46 2 EPISCL ERM 4 FB GCA 2 6 GL PERF H ACHE 16 HSV KE HZO 1 13 IOFB L CYST 1 M GRAVIS MACULO 6 MARG K MIGRAINE 9 MINOR TR MYO CNV 2 NIL ON 15 PAPILLO PCO 38 6 POST OP P SEP CEL PSII PTERY 9 PTOSIS PVD CRAO RC CO ER 1 RD RET SCHI 18 1 DR RUB GLA 1 45 CRVO SCH SCLER SINUS 5 18 SLK TIA 122 1 10 TR AAU TR HYPH 52 1 9 TRICHIA VIT HE TopTop 1010 –– EyeEye Casualty!Casualty! 1. SeasonalSeasonal allergicallergic conjunctivitisconjunctivitis 2. AnteriorAnterior UveitisUveitis 3. InfectiveInfective ConjunctivitisConjunctivitis 4. CornealCorneal AbrasionAbrasion 5. DryDry EyeEye 6. EpiscleritisEpiscleritis 7. CornealCorneal FBFB 8. HSKHSK 9. MarginalMarginal KeratitisKeratitis 10. PVDPVD 11. TrichiasisTrichiasis ContactContact LensLens WorkWork CURRENTCURRENT PRACTICEPRACTICE Meibomian TRICHIASIS THYGESONS EXTERNALEXTERNAL EYEEYE Dry Eye Allergy Infection Auto Trauma Toxic Other Immune Mechanical Evaporative Non Evaporative Non Chronic Acute Viral Episcleritis Foreign Chemical Angle Evaporative Chronic Acute Viral Episcleritis Foreign Chemical Angle Evaporative Body Closure Body Closure Glaucoma Vernal Seasonal Bacterial Pemphigoid Glaucoma Vernal Seasonal Bacterial Pemphigoid Injury Microbial Injury Microbial Atopic Perennial Inclusion Toxins Atopic Perennial Inclusion Uveitis Toxins Rosacea Uveitis Rosacea GPC Parasitic GPC Parasitic Vasculitis Trichiasis Vasculitis Trichiasis Fungal Fungal Scleritis Scleritis ClinicalClinical DecisionDecision MakingMaking DIAGNOSIS REFERRAL COMMON CONDITIONS not normally sight threatening sight threatening Prescription Immediate First Aid Alleviation Prescription & Referral + - & Referral Urgent Referral Palliation Management Blepharitis Microbial keratitis Acute glaucoma Anterior uveitis Corn. abrasion External Eye Disease Patient Pathway Patient Presentation Optometrist / GP Suspected external Suspected external eye eye disease disease Optometrist Diagnosis Conditions that are normally Common conditions that are sight threatening (should not normally sight threatening If sight threatening condition is therefore be managed in (can therefore be managed in Condition not normally Diagnosis identified secondary care) for example: the community) for example: sight threatening uncertain Anterior Uveitis Dry Eye Inclusion Corneal Abrasion Scleritis Foreign bodies Endophthalmitis Blepharitis Optometrist/GP Cellulitis Episcleritis URGENT REFERRAL Management Microbial Keratitis Bacterial conjunctivitis Advice Angle Closure Glaucoma Conjunctival haemorrhage Prescription Chemical Burns Hordeola Marginal Keratitis Allergic, Toxic or Viral Neoplasia external eye conditions If no response or there is concern Hospital Eye Service Optometrist/GP Refer to Hospital Eye Service for diagnosis Follow up & discharge and appropriate management Self Care Primary Care Secondary Care HistoryHistory n AgeAge // SexSex n GeneralGeneral HealthHealth n POHPOH n FamilyFamily HistoryHistory n RecentRecent HistoryHistory n OnsetOnset // DurationDuration // SymptomsSymptoms stablestable oror varyingvarying oror regressingregressing n PainPain // rednessredness /vision/vision /photophobia/photophobia n PresentationPresentation –– recurring/recurring/ // Intermittent?Intermittent? WhatWhat isis thethe problem?problem? n PainPain vv NoNo PainPain -- ?? severityseverity n RedRed vv WhiteWhite n VisualVisual LossLoss vv NormalNormal VisionVision n ?? FloatersFloaters // PhotopsiaPhotopsia n Duration:Duration: RecentRecent vv LongLong TermTerm ExaminationExamination n VAVA /Pinhole/Pinhole n PupilsPupils n OcularOcular MotilityMotility n AnteriorAnterior SegmentSegment –– lids/lashes/red?/conj/cornea/anteriorlids/lashes/red?/conj/cornea/anterior chamberchamber n InternalInternal –– Lens/vitreous/retina/macula/opticLens/vitreous/retina/macula/optic nervenerve n ApplanationApplanation tonometrytonometry n SlitSlit LampLamp n VolkVolk –– DILATE!DILATE! n GonioGonio n VisualVisual FieldsFields // confrontationconfrontation PointsPoints toto PonderPonder Upper Lower Lashes Tarsal Fornices Limbus Plica Lid Margin Adnexa FolliclesFollicles vv PapillaePapillae Papillae consist of hyperplastic conjunctival tissue full of inflammatory cells, normally seen in the palpebral conjunctiva. Associated with bacterial, and allergic conjunctivitis Follicles consist of hyperplastic lymphoid tissue & appear as elevated lesions encircled by blood vessels. Typically seen in reaction to topical agents, adenoviral & chlamydial disease ExternalExternal EyeEye ProblemsProblems DryDry EyeEye Tear EvaporativeEvaporative Tear DeficientDeficient Meibomian Lid Problem Other Gland Disease Non-Sjogren’s Sjogren’s Exposure Glands Lacrimal Disease Missing CL (Distichiasis) Primary Primary Ocular Surface Ant / Post (Xerophthalmia) Secondary Blepharitis Secondary Abnormal Lacrimal Gland Blink Obstruction Auto Immune Abnormal Disease Aperture Loss of Reflex Tearing Incongruous Surface TestsTests n SchirmersSchirmers type1type1 withwith anaesthesiaanaesthesia typetype 22 asas 11 withwith nasalnasal irritationirritation whatmanwhatman nono 4141 filterfilter paperpaper << 10mm10mm abnormal.abnormal. << 3mm3mm conculsiveconculsive n TearTear BreakBreak UpUp timetime fluorsceinfluorscein stainstain tearfilmtearfilm << 1010 secsec abnormalabnormal (average(average ofof 33 tests)tests) TreatmentTreatment overviewoverview Castor oil Tear secretors Meibomium lid disease Artificial tears Immunosuppressive Warm compresses Plugs or occlusion Omega 3 fatty acids Moisture chambers Mucin secretors Androgen drops MechanicalMechanical StimulationStimulation Hot Compresses Lid Massage Lid Scrubs LubricantsLubricants PromotePromote Healing!Healing! Goblet Cell Density & Preservatives Normal They’re goblet cell decreased density in Dry Eye Treated with preservative free lubricants Lubricant preserved with Benzalkonium Chloride Choices?Choices? Choices?Choices? Choices?Choices? Avoid Benzalkonium Chloride! TreatmentTreatment retentionretention –– PunctumPunctum PlugsPlugs PlasticPlastic oror siliconesilicone plugsplugs oror CollagenCollagen Removable?Removable? CanCan fallfall outout CanCan irritateirritate Infection?Infection? CanCan convertconvert aa drydry eyeeye toto aa wetwet oneone BlepharitisBlepharitis AnteriorAnterior PosteriorPosterior BLEPHARITIS 1. Anterior • Staphylococcal • Seborrhoeic 2. Posterior • Meibomianitis • Meibomian seborrhoea 3. Treatment Staphylococcal blepharitis • Chronic irritation worse in mornings • Hyperaemia and telangiectasia of anterior lid margin • Scales around base of lashes (collarettes) • Scarring and hypertrophy if longstanding Complications of blepharitis Trichiasis,madarosis,poliosis Recurrent styes Marginal keratitis Tear film instability Seborrhoeic blepharitis • Shiny anterior lid margin • Greasy scales • Hyperaemia of lid margin • Lashes stuck together Treatment of Blepharitis 1.1. LidLid hygienehygiene // LidLid ScrubsScrubs withwith 50%50% babybaby shampooshampoo // SuprannettesSuprannettes // LidLid CareCare 2.2. TearTear substitutessubstitutes -- forfor associatedassociated teartear filmfilm instabilityinstability 3.3. WarmWarm compressescompresses -- toto meltmelt solidifiedsolidified sebumsebum inin posteriorposterior blepharitisblepharitis // ?? EyebagEyebag 4. Topical antibiotics (Fucidic Acid) & steroids 5.5. SystemicSystemic tetracyclinestetracyclines // TopicalTopical SteroidsSteroids -- forfor severesevere blepharitisblepharitis HordeolaHordeola InternalInternal ExternalExternal Chalazion (meibomian cyst) Painless, roundish, firm lesion May