Common eye condition in General Practice

common eye condition in GP

1. Topics today..

2. ARMD Age related disease involving the macula (usually bilaterally) which can result in blurred or reduced vision in the centre of the visual field. Commonest cause of severely sight impaired and sight impaired in the >60yrs in the UK. -Increased prevalence due to ageing population. - AMD in one eye, the risk of the contralateral eye developing AMD is 39-55%.   Types: 1. Dry macular degeneration (atrophic) = 90% =Less severe than wet AMD but cannot be cured. -Pathophysiology = Macular pigment, bleeding and precursor drusen -> geographic retinal atrophy and macula degeneration   2. Wet macular degeneration (neovascular/exudative) = 10% = more severe but can be treated -Pathophysiology = CNV -> macular scar and oedema

3. ARMD Symptoms: Gradual (years) bilateral blurring/loss of central visual filed (central scotoma) and reduced visual acuity Difficulty with night vision and changing light conditions Vision fluctuates daily Fundoscopy: Dry = drusen, geographical retinal atrophy Wet = greyish/green retinal discolouration, macular neovascularisation and haemorrhage Risk Factors: Increasing age Smoking Family history of AMD CVD risks such as HTN, obesity, hypercholesterolaemia

4. ARMD Treatment Dry AMD = no treatment which can halt or reverse progression and vision loss. Impaired sight registration Sight impaired (partial) = <6/60 or Severely sight impaired (blind) = <3/60 Low vision aids e.g. magnifiers for reading, social support , p sychological support etc. Wet AMD : Conservative measures e.g. smoking cessation and increasing green vegetables in diet Anti-VEGF intravitreal injections (multiple injections for up to 2 years and may restore some vision). Laser Photocoagulation

5. Cataracts Opacification (clouding) of the natural crystalline lense resulting in gradual deterioration of vision Leading cause of blindness worldwide , usually >65yrs Causes: Ageing (commonest cause – almost everyone >65yrs has a degree of cataract) Congenital (i.e. genetic) Traumatic (e.g. lens capsule disruption) Secondary to systemic disease e.g. Myotonic dystrophy Secondary to ocular disease e.g. post inflammatory Drug induced e.g. due to steroid use

6. Cataracts Symptoms: Often develop slowly and can be uni or bilateral Gradual blurring/misting/clouding of vision i.e. reduced visual acuity Painless visual field loss Glare /dazzle (light scatters in vision) Halos around lights/difficulty driving at night Myopia (short sightedness)   Fundoscopy: Grey/white pupil Reduced red reflex in immature and absent in dense cataracts

7. Treatment Refractive error correction Surgery = phacoemulsification to remove cataract + posterior chamber artificial intraocular lens (IOL) insertion

8. Diabetic Retinopathy DM is the leading cause of blindness in 20-65yrs.   Diabetic Retinopathy affects up to 80% of those with DM for 20+ years. Commonest cause of blindness in young people (<65yrs). Presentation: May be asymptomatic and picked up at annual retinal pre-symptomatic screening   Gradual clouding/blurring of vision affecting daily activities e.g. driving (often central vision) Sudden vision loss (vitreous haemorrhage ) Floaters (dots, specks or streaks in the vision) Decreased visual acuity and central scotomas (suspect maculopathy e.g. macula oedema) Diagnosis: visual acuity (Snellen chart), visual fields Fundoscopy Slit lamp examination FFA

9. Diabetic Retinopathy Grading classification: Each eye is graded according to the following categories: R0 (none) R1 (background = dots, flares, exudates) R2 (pre-proliferative = cotton-wool spots, retinal ischaemia ) R3 (Proliferative = new vessels + vitreous haemorrhage )  

10. Diabetic Retinopathy Management: Optim ise HbA1c, blood pressure and cholesterol control 1. B ackground retinopathy = observation 2. P re-proliferative = refer to ophthalmologist to consider panretinal laser photocoagulation 3. P roliferative = urgent referral for panretinal laser photocoagulation 4. E nd stage = vitreoretinal surgery e.g. vitrectomy   Prevention: Annual retinal screening of diabetic patients for eye disease.

11. Blepharitis Chronic inflammation of the eyelid margins due to blocked Meibomian gland Causes: Bacterial infection e.g. Staph aureus/epidermis Associated with skin condition e.g. acne rosacea, seborrheic dermatitis Symptoms: Sore, dry eyes bilaterally and gritty, foreign body sensation Scaling of the eyelids and crusting on lashes Complications: Conjunctivitis , keratitis, ulceration, styes, chalazion

12. Blepharitis Management: a. Good lid hygiene including Gentle cleaning Warm compresses = clean, warm, wet washcloth for 5 mins (softens and loosens crusts) Gentle eyelid massage and rolling a cotton-tipped applicator sideways along the eyelids to remove residue lipids from the glands. Lubricant eye drops (artificial tears) e.g. Hylo b. If clear bacterial infection or gland dysfunction, consider: Abx ointment Low dose oral Doxycycline

13. Conjunctivitis Causes: Virus (adenovirus) B acterial (Staph, Strep, Haemophilus ) Symptoms (viral = always bilateral, bacterial may be bilateral) Red eye Mild irritation/gritty sensation Watery/sticky eyes (serous discharge or purulent in bacterial) Rarely affects vision (unless cornea affected) No pain or photophobia

14. Conjunctivit is Treatment Both Good general hygiene e.g. do not share towel (highly contagious) Viral Usually self-limiting after few weeks Symptomatic relief with warm compress, topical lubricants (artificial tears) and topical antihistamines Bacterial Usually conservative as most will self-resolves in about two weeks Symptomatic relief with warm compress, topical lubricants (artificial tears) If severe e.g. Topical Abx (eye drops) e.g. Chloramphenicol 0.5% ointment Consider delayed prescription where pt only takes Abx if not resolved in 3 days.

15. Corneal abrasion Erosion causing loss of corneal epithelium due to trauma (foreign object, contact lens, chemical injury) Symptoms: Red, watery eye Moderate to severe pain B lurred vision (if abrasion crosses visual axis) Photophobia Fluorescein stain under slit-lamp microscope: U se blue light Green stains = epithelial loss Complications: Bacterial Keratitis Treatment: Mydriatic (dilator) drops, prophylactic topical abx , eye padding . Cornea usually heals within 48hrs (reassessment if not resolving/deteriorating)