11/11/21

GP Teaching- Common eye conditions

Mr. Saurabh Goyal, MBBS, MS, DNB, FRCS, FRCOphth
Consultant St. Thomas’ Hospital
Honorary Lecturer, Kings College London

www.eyesurgeonlondon.co.uk
bm ihealthcare.co.uk

020 313 77626

Plan

45-50 mins

Introductions

Questions

Eye emergency services

Common eye conditions

Red eye, red flags

Covid related eye issues

Questions

1
 11/11/21

Acknowledgements
• Univadis- BMJ learning

Introductions
• Consultant- St. Thomas’ (Glaucoma and cataracts)

• Ex Consultant- Queen Mary’s

• Fellowship- Glaucoma, Moorfields

• Fellowship- Cornea & anterior segment, St. George’s and

Moorfields

• Fellowship- Glaucoma- St. Thomas’ and Kings

• Specialist Registrar- London and Birmingham

2
 11/11/21

Walk- in Eye emergency services

• Diminishing
• www.primar yeyecare.co.uk (MECS optometrists)

• Sidcup (Kings)
kch-tr.qmsrapideyeser [email protected]

• Kings- 020 3299 9000 Ext: 35465

Email [email protected]

• Moorfields

020 7521 4682 (NUMBER NOT TO BE GIVEN TO PATIENTS)- Moorfields

[email protected]
Phone Number
t: 020 7566 2345

Google eye emergency ser vices map London

• St Thomas’-
020 7188 4336 (eye emergency clinic advice and triage)
020 7188 7188 (switchboard)

Case- 32 year painful+ red eye

-HZO

-Acyclovir 800mgx5
day- 5-7 days

-Tip of nose
involvement-
Hutchinson’s sign

- ie more risk of
intraocular
involvement

- Conjunctivitis, corneal
Pseudodendritic ulcer,
uveitis, 4th nerve palsy

3
 11/11/21

Follow up
• Rashes, double vision,
uveitis improving

Herpes Zoster Ophthalmicus

• Systemic anti-virals,
Acyclovir, Valacyclovir

• Corneal ulcer- Virgan

ointment
(0.15% Gancivlovir)

• Topical steroid if intraocular

inflammation

• Management of Post
Herpetic neuralgia

4
 11/11/21

Lockdown remote consultation-

?chalazion

F2F- vesicles

10

5
 11/11/21

Treatment and follow up- 1 day-

improved with Systemic Acyclovir

Herpes simplex blepharitis

11

Herpetic Keratitis

Virgan eye ointment, Systemic anti-virals

12

6
 11/11/21

Lid swellings

Internal hordeolum (acute meibominitis) chronic- Chalazion

13

Acute hordeola
Internal hordeolum External hordeolum (stye)
( acute chalazion )

Staph. abscess of meibomian Staph. abscess of lash follicle and

glands associated gland of Zeis or Moll

14

7
 11/11/21

Chalazion

Chalazion

minor ops referral for incision and curettage

15

Stye versus chalazion

16

8
 11/11/21

Treatment
Stye Chalazion (acute)/ chronic

• Anti-inflammatory • Hot fomentation, massage

• Hot fomentation • Anti-inflammatory (Ibuprofen,

Steroid-antibiotic ointment-
• Remove eye lash e.g. Maxitrol, Betnesol

• Treatment of associated
blepharitis

• Incision and curettage

17

Blepharitis Examination
Posterior blepharitis- blocked
glands Anterior blepharitis- collarettes

Plugged gland

18

9
 11/11/21

Posterior blepharitis
Optase Moist heat mask/Eye bag Massage

19

Unblocking
Needle/probing Firm pressure

20

10
 11/11/21

Posterior blepharitis-TEAR FILM

Bubbles, also called frothing, can sometimes be seen in the tear
film, especially along the lid margins. This can indicate
meibomianitis.

21

Posterior blepharitis
Toothpaste like secretions Treatment- post blepharitis
• Hot fomentation
• Massage
• Azyter eye drops
(Azithromycin 2/day for 3 days then
one/day for 6 days)
• Azithromycin tablets- 500mg day 1 then
250mg for 5-7 days
• Doxycycline- 50mg/day for 6-8 weeks
• Fish oil capsules, Flaxseed oil capsules
• Anti-inflammatory
• Meibomian gland probing, lipiflow, pulse
light therapy
• Lubricants

22

11
 11/11/21

Anterior (Staphylococcal) blepharitis

Chronic irritation worse in morning • Hyperaemia and telangiectasia of

anterior lid margin
• Scales around base of lashes • Scarring and hypertrophy if
(collarettes) longstanding

23

Anterior blepharitis
wipes Treatment

• Lid cleaning (avoid

shampoo)

• Antibiotic ointment

• Tear drops

24

12
 11/11/21

Case work
Preseptal cellulitis
62 year old Gardener

Scratched by a twig 3/7 ago

Red and tender

Eye movements and vision are

normal

25

Case work

33 year old

History of sinus disease

Painful eye, bulging

Painful eye movements Orbital Cellulitis

Decreased vision

Fever, unwell Urgent referral, admission, systemic antibiotics,

imaging, drainage (sinus abcess),
risk of Cavernous Sinus Thrombosis

26

13
 11/11/21

Lid swelling

Preseptal cellulitis Orbital cellulitis

Proptosis, Ocular Movement ,

Vision , Pupil, fundus, CT scan.

27

Red flag
• Painful eye movements- sign of inflammation

• Look for proptosis, pupils, vision, colour vision

• Orbital inflammation/infection

28

14
 11/11/21

Case- glue in the eye

29

Necrotizing Fasciitis

30

15
 11/11/21

Lockdown case

31

Progression

Pingecula Early Pterygium Advanced pterygium

32

16
 11/11/21

Case work
• 40 year old woke up with
sticky and red eyes

• Watering

• Recent cold, work

colleague also had the
same
• One eye then the second
eye a few days later

33

Infective Conjunctivitis
• Most resolve within 1-2 weeks

• Viral> bacterial

• Non-resolving- consider chlamydial testing

• Variable pain, photophobia, slight decrease in

vision.

• Check vision and do F-stain of cornea

34

17
 11/11/21

Case work
• 23 year old unilateral red
Follicular conjunctivitis- ?Chlamydial eye for 2 months
• Watery, mild
stickiness/discomfort, vision
ok

• Single, visited Amsterdam 3

months ago

35

Case work
Itching=Allergic eye disease

18 year old, bilateral, redness, itchy, watery, happened last year, runny nose,
sneezing

36

18
 11/11/21

Allergic eye disease

Seasonal Allergic VKC (Vernal Keratoconjunctivitis)

37

Treatment for allergic eye disease

• Cold wash

• Avoid allergens (goggles, wash, change clothes, windows)

• Tear drops
• Sodium Cromoglycate 2% drops 2-3/day (need days to weeks)

• Olapitidine- 2/day (opatanol)

• FML (steroid)- 2-3/day in acute exacerbations (short course- 5-7 days) (start mast
cell stabilizers early)

38

19
 11/11/21

Case work

• 62 year old GPs mother

• Monthly disposable
contact lens wearer

• Woke up with redness and

pain in the eye

• Watery, mild ache, vision

OK

39

Red Flag- Contact lens wear

infiltrate Pseudomonas Ulcer

40

20
 11/11/21

Severe Pseudomonas keratitis

41

Contact lenses
• Rigid Gas permeable (RGP) & daily disposable less risk of
infection than extended wear lenses

• Sleeping in lenses- increased risk

• Contact lens case hygiene

• Carry glasses

• Seek urgent medical attention

42

21
 11/11/21

Sequalae of contact lens- corneal

scarring

43

History taking for red eye

• Unilateral or bilateral

• Acute or chronic or recurrent

• Previous eye history- uveitis, hay fever, surgery, erosions

• Contact lens use

• Medications (glaucoma)

• Trauma (drilling/blunt trauma)

44

22
 11/11/21

Associated symptoms
• Itching

• Discharge- watery/mucus/mucopurulent

• Photophobia

• Pain

• Decreased vision

• Double vision

• Floaters

• Nausea/Vomiting/Headache
• Recent flu/contact with someone with red eye

45

Red Flag
• Red eye with decreased vision

• Corneal ulcer/acute glaucoma/posterior

uveitis/endophthalmitis

46

23
 11/11/21

Acute Attack of Angle Closure

Case work
68 year old female

Long sighted

Woke up at 3am with

painful eye, headache,
vomited

Hazy cornea, fixed dilated

pupil

47

Acute Angle Closure

• Headache

• Nausea and vomiting

• Severely reduced vision

• Hazy cornea

• Dilated fixed/sluggish pupil

• Hard eye

48

24
 11/11/21

Laser iridotomy

49

EAGLE Trial Results (one centre)

36 months Follow-up
Laser PI (av. 69yrs) Lens extraction + IOL (62 yrs)

IOP Drops IOP Drops

Av. Pre -op IOP 30mmHg - 34mmHg -

6 months 22mmHg 1.5 14mmHg 0.2

12 months 18mm Hg 2.5 15mmHg 0

36 months 18mmHg 2.5 16mmHg 0

Change -12mmHg 2.5 drops -18mmHg No drops

Lancet 2016, Lens extraction is more effective than laser iridotomy

for primary angle closure glaucoma

50

25
 11/11/21

Post-operatively (UBM)
RIGHT LEFT
(phakic) (pseudophakic)

51

Tetanus, ciprofloxacin/ofloxacin, NBM,

shield

52

26
 11/11/21

Case

53

Foreign body

54

27
 11/11/21

Lockdown sequelae

55

Advancements in IOLs
Trifocal IOLs

• Good Dist. Near and

Intermediate vision

56

28
 11/11/21

EDOF (Extended depth of focus lenses)

Minimal/similar to Monofocal glare and halos

Good distance and intermediate vision, big print

reading

57

57

Presentation
• 45 year old male

• Bilateral Red eyes, gritty, itchy and uncomfortable around lid margins

• Flaky discharge at times

• Prednisolone drops- 8 years

• IOP- 60mmHg and 50mmHg, Bilateral cataracts

58

29
 11/11/21

Advanced right eye glaucoma damage

59

Visual fields
Left eye- Normal Right eye- Advanced loss

60

30
 11/11/21

Surgery
Right eye Trabeculectomy- Left eye Phako+IOL+istent tube
IOP8mmHg, no drops IOP 20mmHg no drops

61

Steroids
• Any form of steroids can cause IOP to rise

• Particularly eye drops

• Ointment in the eye

• Steroids around the eye

• If drops related problems avoid Hydrocortisone

62

31
 11/11/21

Lockdown Advanced glaucoma-

Afrocarribeans

63

Combined Trab and Tube surgery

64

32
 11/11/21

65

Post operative endophthalmitis

• Acute decreasing vision, pain, red eye

• Endophthalmitis until proven otherwise

• Prompt referral

• Usually within 1-2 weeks after surgery

• Poor red reflex on direct ophthalmoscope

66

33
 11/11/21

Floaters
• Common problem

• If gradually increasing- vitreous degeneration

• If sudden onset with flashing with/ without

decrease in vision- PVD

• Dilated fundus examination to rule out retinal

tear/ detachment

67

Retinal detachment
1. Vitreous gel liquifies (floaters)
2. May pull retina if attached (flashes)
3. Causes a hole
4. Fluid enters hole
5. Retina peels off
(more floaters, vision affected)
6. Dilate pupil, with careful look usually
obvious

68

34
 11/11/21

Equipment
• Snellen acuity chart and Pin hole

• Torch and/or ophthalmoscope with blue filter

• Fluorescein drops or impregnated paper

• Topical Anaesthesia- Tetracaine/ Benoxinate drops

• Topical short acting mydriatic- Tropicamide 0.5% or 1%

• (Phenylephrine 10%)

69

One Equipment

70

35
 11/11/21

Ipad/iphone/Android apps
• Eye Handbook

• Snellen acuity

71

Eye Handbook- iphone/android

Testing
• Duochrome
• Amsler
• Torch
• Pupil chart
• Colour vision
• Ruler
• Worth 4 dot
• OKN

72

36
 11/11/21

Covid related eye problems

• Risk to eye care professionals

• IL 1 receptors in the conjunctiva-

likely portal of infection

• Viral conjunctivitis in early stages

• Inflammatory red eye later on

(?episcleritis)

• Rarely conjunctivitis as the only

or first manifestation

• Retinal thrombosis

73

Pattern Recognition
Horse, Zebra or Giraffe?

74

37
 11/11/21

Thank you for your attention

www.eyesurgeonlondon.co.uk

020 313 77626

bm ihealthcare.co.uk

75

38