Declaration of interests

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Declaration of interests
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• I have declared that I have no interests

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Diagnosis?
Header
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Handbook Page 202
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Questions
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• What dermatological conditions may accompany this
  eyelid problem?

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Questions
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• What dermatological conditions may accompany this
  eyelid problem?
• What eyelid or ocular complications can occur
  from this condition?

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Questions
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• What dermatological conditions may accompany this
  eyelid problem?
• What eyelid or ocular complications can occur
  from this condition?
• What is the management?

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Questions
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• What dermatological conditions may accompany this
  eyelid problem?
• What eyelid or ocular complications can occur
  from this condition?
• What is the management?
• What serious condition can mimic this condition
  when it occurs unilaterally?

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History of recurrent sticky eye since birth.
Diagnosis?
Header
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Handbook Page 201
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Questions
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• What is the appropriate management ?

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This patient presents with an acute red eye
Header
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Handbook Page 201
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Questions
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• What questions should we ask him?

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Questions
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• What questions should we ask him?
• How should we examine him?

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Questions
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• What questions should we ask him?
• How should we examine him?
• What is the management?

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Why is the development of a red eye in a patient
wearing contact lenses potentially serious?
Header
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Handbook Page 201
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12 yr old boy presents with pain, diplopia,
decreased vision, feels unwell
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Diagnosis?
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• What is the appropriate management?

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Patient presents with red eye and tenderness over
area of injection
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Handbook Page 201
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Diagnosis?
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Handbook Page 201
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Questions
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• What is the differential diagnosis

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Questions
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• What is the differential diagnosis?
• What is the appropriate management?

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The red eye fill in the gaps
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Sudden onset of severe itching and
irritationDiagnosis?
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Handbook Page 201
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Questions
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• What would you prescribe and why?

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Diagnosis?
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Handbook Page 200/203
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Questions
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• What symptoms will this patient have experienced?

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Questions
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• What symptoms will this patient have experienced?
• Is this an urgent or non-urgent problem?

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Questions
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• What symptoms will this patient have experienced?
• Is this an urgent or non-urgent problem?
• What is the appropriate management?

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Patient presented with acute distortion of
vision. Diagnosis?
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Handbook Page 199/201/203
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• What are risk factors for the development of this
  condition?

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Questions
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• Is this an urgent or non-urgent problem?
• What are risk factors for the development of this
  condition?
• What is the appropriate management?

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Diagnosis?
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Handbook Page 203/204
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• What symptoms will the patient have?

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Questions
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• Is this an urgent or non-urgent problem?
• What symptoms will the patient have?
• Are there any systemic implications for its
  treatment?

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Diagnosis? Blepharitis
Header
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Handbook Page 202
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Questions
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• What dermatological conditions may accompany this
  eyelid problem?

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Questions
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• What dermatological conditions may accompany this
  eyelid problem?
• Seborrhoeic dermatitis/acne rosacea

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Questions
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• What eyelid or ocular complications can occur
  from this condition?

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Questions
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• What eyelid or ocular complications can occur
  from this condition?
• Chalazion (meibomian cyst)
• Styes
• Trichiasis
• Dry eye
• Corneal ulcers

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Chalazion
Header
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Handbook Page 202
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Complications of blepharitis
Header
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Handbook Page 202
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Questions
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• What is the management?

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Practical management tips
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• Lid hygiene - with 25 baby shampoo
• Tear substitutes - for associated tear film
  instability
• Systemic tetracyclines - for severe posterior
  blepharitis
• Warm compresses - to melt solidified sebum in
  posterior blepharitis

Handbook Page 202
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Treatment of chronic blepharitis
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• Lid hygiene Blephaclean wipes and Blephasol
• Tear substitutes Hyabak drops
• Warm compresses The Eyebag
• www.faceandeye.co.uk

Handbook Page 202
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Blephaclean wipes
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Blephasol solution
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Hyabak drops
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The Eye Bag
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Take away message
Header
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• Do not prescribe steroid drops/ointments

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Do not prescribe steroid eye drops/ointments
Header
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Why not?
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Steroids can cause
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• Cataracts
• Glaucoma
• Infection

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Steroids can cause
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• Cataracts
• Glaucoma
• Infection
• In addition to dramatic worsening of HSK

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Questions
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• What serious condition can mimic unilateral
  blepharitis or chronic chalazion?

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Questions
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• What serious condition can mimic unilateral
  blepharitis or chronic chalazion?
• Sebaceous gland carcinoma

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Masquerage syndrome
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History of recurrent sticky eye since
birthDiagnosis?
Header
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Handbook Page 201
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History of recurrent sticky eye since
birthDiagnosis? Congenital NLD obstruction
Header
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Handbook Page 201
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Questions
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• What is the appropriate management ?

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Questions
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• What is the appropriate management ?
• Topical Fucithalmic
• Massage over the lacrimal sac in a downward
  direction
• Most cases resolve spontaneously by age of 2
  years
• Refer those that persist or associated with other
  problems e.g. lacrimal sac mucocele

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This patient presents with an acute red eye
Header
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Handbook Page 201
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Questions
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• What questions should we ask him?

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Questions
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• What questions should we ask him?
• Visual problem?
• Pain?
• Discharge?
• URTI?
• Travel?
• Contacts?

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Questions
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• How should we examine him?

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Questions
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• How should we examine him?
• Visual acuity
• Cornea
• Fornices looking for follicles
• Lymphadenopathy

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Questions
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• What is the management?

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Questions
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• What is the management?
• Swabs bacterial, viral, chlamydial
• Topical antibiotics
• Strict hygiene
• Steroids for adenoviral keratoconjunctivitis
  under supervison of ophthalmologist
• Tetracycline/Erthromycin for chlamydia with
  referral to GU clinic

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Why is the development of a red eye in a patient
wearing contact lenses potentially serious?
Header
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Handbook Page 201
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Risk of serious sight threatening infection

• 55 years old male
• 30 days continuous wear CL
• 1 day h/o FB sensation
• S/B AE- abrasion given CPL
• 3 days later increase pain and decrease vision
• Growth of Pseudomonas

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Acanthamoebic keratitis
Header
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Can be extremely painful Contact lens wearers
particularly predisposed Associated with poor
hygiene
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Take away message
Header
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• Refer patients with a red eye and a history
  of contact lens wear to an ophthalmologist

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12 yr old boy presents with pain, diplopia,
decreased vision, feels unwell
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Diagnosis?
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Diagnosis? Orbital cellulitis with subperiosteal
abscess
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• Urgent

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Questions
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• What is the appropriate management?

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Questions
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• What is the appropriate management?
• Immediate antibiotics - ciprofloxacin
• - clindamycin
• Urgent referral to hospital
• Keep nil by mouth

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Orbital cellulitis with subperiosteal abscess
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Patient presents with red eye and tenderness over
area of injection
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Handbook Page 201
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Diagnosis?
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Handbook Page 201
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Diagnosis? Episcleritis
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Handbook Page 201
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Questions
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• What is the differential diagnosis

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Questions
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• What is the differential diagnosis
• Scleritis

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Questions
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• What is the appropriate management?

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Questions
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• What is the appropriate management?
• Oral anti-inflammatory agent

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The red eye fill in the gaps
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The red eye - making the diagnosis
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Handbook Page 201
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Iritis
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• Note circumcorneal injection and irregular pupil
  (after dilating drops)

Handbook Page 201
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The red eye - making the diagnosis
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Handbook Page 201
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Diagnosis? Episcleritis
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Handbook Page 201
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The red eye - making the diagnosis
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Handbook Page 201
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Scleritis
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• Variable appearance
• Can result in scleral necrosis with underlying
  uvea showing through

Handbook Page 201
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Management
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• Iritis (refer)
• Topical steroid (Predsol Forte 2 hourly)
• Topical dilating agents (Cyclopentolate 1)
• Episcleritis (advise and treat?)
• Usually self limiting
• Topical lubricants and oral NSAIDS can speed
  recovery
• Scleritis (refer)
• Variable dependent on type and aetiology
• From oral NSAID to topical steroid to systemic
  immunosuppresion

Handbook Page 201
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Sudden onset of severe itching and
irritationDiagnosis?
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Handbook Page 201
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Questions
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• What would you prescribe and why?

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Questions
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• What would you prescribe and why?
• Opatanol
• (Olopatadine hydrochloride) antihistamine
• Opticrom
• (Sodium cromoglycate) mast cell stabiliser

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Diagnosis?
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Handbook Page 200/203
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Diagnosis? Retinal detachment
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Handbook Page 200/203
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Posterior vitreous detachment (PVD)
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Handbook Page 200/203
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Questions
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• What symptoms will this patient have experienced?

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Questions
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• What symptoms will this patient have experienced?
• Flashing lights (photopsia), floaters, and a
  shadow encroaching on the visual field from below

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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• Urgent if referral is delayed the retinal
  detachment will involve the macula with a
  permanent central visual loss even with
  successful reattachment of the retina

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Questions
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• What is the appropriate management?

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Questions
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• What is the appropriate management?
• Urgent referral to an ophthalmologist
  (vitreo-retinal surgeon)

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Take away message
Header
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• A patient complaining of flashing lights and
  floaters has a retinal tear/retinal detachment
  until proven otherwise and should be referred to
  the acute ophthalmic referral centre

Handbook Page 200/203
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Patient presented with acute distortion of
vision. Diagnosis? Wet macular degeneration
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Handbook Page 199/201/203
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• Urgent

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Dry macular degeneration
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Handbook Page 199/201/203
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ARMD
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Handbook Page 199/201/203
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Amsler grid
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Handbook Page 199/201/203
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Questions
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• What are risk factors for the development of this
  condition?

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Questions
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• What are risk factors for the development of this
  condition?
• Main factors are age, diet, hypertension,
  exercise ( regular exercise reduces risk by 70),
  genes,  smoking (even passive), alcohol and skin
  pigment ( more frequent in Caucasians than
  Afro-Caribbeans).

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Questions
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• What is the appropriate management?

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Questions
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• What is the appropriate management?
• Urgent referral to an ophthalmologist
• May require intravitreal injections (Lucentis or
  Avastin), steroid injections, PDT

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Take away message
Header
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• A patient complaining of acute distortion of
  vision (metamorphopsia) should be referred to an
  ophthalmologist without delay

Handbook Page 199/201/203
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Diagnosis?
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Handbook Page 203/204
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Diagnosis? Glaucomatous cupping and atrophy of
the optic disc
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Handbook Page 203/204
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Questions
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• Is this an urgent or non-urgent problem?

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Questions
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• Is this an urgent or non-urgent problem?
• Non-urgent

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Questions
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• What symptoms will the patient have?

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Questions
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• What symptoms will the patient have?
• The patient may be asymptomatic or may have
  noticed some visual field loss
• Often picked up on routine opticians test

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Questions
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• Are there any systemic implications for its
  treatment?

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Questions
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• Are there any systemic implications for its
  treatment?
• Beware of the use of topical B-blockers e.g.
  Timolol in patients with obstructive airways
  disease and heart failure
• Beware drug interactions

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Glaucoma
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• Q. What are the first and second line drops of
  choice?
• First line Xalatan/Travatan/Lumigan
• Second line Timolol / Azopt

Handbook Page 203/204
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What have we learned?
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• Blepharitis - masquerade syndrome
• The red eye avoid steroids
• Contact lens and conjunctivitis serious
• Allergic eye disease rationale for drops
• Orbital cellulitis an ophthalmic emergency
• Retinal detachment urgent referral
• ARMD urgent referral for acute symptoms
• Glaucoma optometrist very useful

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