Eye conditions the GP can manage or should recognise"

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Eye conditions the GP can manage or should
recognise"

• Mitch Menage
• Consultant Eye Surgeon
• Leeds Teaching Hospitals Trust

GP Meeting March 2014
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Blepharitis

• Chronic inflammation of the lid margins
• Common
• Remitting
• Range of ages
• Bilateral
• Often misdiagnosed as conjunctivitis

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Blepharitis

• Lid anatomy
• Types
• Associated conditions
• Symptoms
• Signs
• Treatment

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Lid anatomy
Meibomian/tarsal glands Glands of Zeiss and Moll
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Lid anatomy
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Blepharitis-Types

• Anterior staphylococcal/dandruff
• Yellow flakes on lid margin
• Posterior sebborhoeic
• Inflamed red oily lid edges

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Blepharitis
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Staphylococcal Blepharitis

• More common young patients
• Chronic infection of base of lashes
• Staph. Aureus
• Associated with styes
• Secondary
• Papillary conjunctivitis
• Punctate corneal erosions
• Marginal keratitis

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Seborrhoeic Blepharitis

• More common older patients
• Excessive lipid secretion meibomian glands
• Meibomitis/MGD
• Lid commensals break down to free fatty acids
• Shiny waxy lids with greasy lashes
• Secondary
• Papillary conjunctivitis
• Punctate corneal erosions

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Acne Rosacea

• Strongly associated with seborrhoeic blepharitis
• Mild forms not diagnosed

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Blepharitis-Symptoms

• Sore burning itching irritation of lids
• Grittiness and watering
• Mild stickiness particularly on waking
• Red lid margins
• Dry eyes

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Signs

• Red lid margins
• Greasy material along margin of lids
• Clogging of meibomian gland openings
• Mild conjunctival injection
• Punctate corneal staining
• Acne Rosacea
• Styes/chalazions

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Chalazion
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Treatment

• Patient education!
• Lid hygiene cotton buds/baby shampoo
• Hot compresses
• Warm flannel 5 mins
• Eyebag
• Lubricants
• Antibiotic gel/ointments
• Oral antibiotic Doxycycline/Limecycline
• Intermittent steroid ointment

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Eyebag
www.eyebagcompany.com
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Dry Eyes

• Lacrimal apparatus
• Tear Film
• Causes/Associated Conditions
• Symptoms
• Signs
• Treatment

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Lacrimal anatomy
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Tear film

• Several layers
• Lipid outer
• Aqueous
• Mucin inner
• Quantity/Quality

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Tear film
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Causes of Dry EyeKeratoconjunctivitis Sicca

• Lacrimal gland aging
• Strongly associated with blepharitis
• Inflammatory conditions
• Rheumatoid arthritis
• Sarcoidosis
• Sjogrens Syndrome
• Laser refractive surgery

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Sjogrens Syndrome
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Sjogrens Syndrome

• Very severe dry eyes
• Middle-aged women
• KCS/Xerostomia and vasculitic disease
• Rheumatoid Arthritis
• SLE
• Scleroderma
• Polyarteritis
• Blood tests
• ANA 70
• SSA(RO) 70 SSB (LA) 40
• RhF 60

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Symptoms

• Feel dry (Can be watery!)
• No relation to emotional tearing
• Gritty burning eyes
• Worsening through day peak in evening
• Worsened by reading, TV, computer
• Worsened by air conditioning, central heating,
  dry arid conditions

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Signs

• Often none!
• Poor tear film on SL with rapid break-up time
• Punctate staining of cornea inferiorly
• Filament strands of mucus on cornea
• Schirmers test

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Signs
Rapid tear break-up time
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Signs
Rose Bengal staining
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Signs
Mucus Filaments
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Schirmers Test
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Treatment - Lifestyle

• Avoid dry situations
• Car heater
• Air conditioners
• Irritants cigarette smoke etc.
• Drugs BP, antidepressant, antihistamine etc
• Increase humidity
• Plants, wet towels, radiator trays etc.
• Humidity chambers
• Wraparound glasses
• Swim goggles

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Treatment-Lubricants

• Liquid drops
• Frequent application
• Gels
• More blurring
• Ointments
• Usually only at night
• Nocturnal lagophthalmos
• Preservative free?

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Liquid Lubricants
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Gel Lubricants
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Ointments
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Other Treatments
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Treatment

• Anti-inflammatory
• Steroid
• Cyclosporin Restasis
• Antimucolytic
• acetylcysteine Ilube
• Oral pilocarpine-Salagen
• Usually only in Sjogrens
• Side effects/limited efficacy

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Treatment

• Punctal occlusion
• Cautery
• Plastic Plugs
• Smartplugs

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Punctal Cautery

• Simple procedure under L/A
• Often preceded by temporary trial occlusion
• Cautery inserted into punctum/canaliculus
• Sometimes not successful
• Permanent and difficult to reverse
• More common to use temporary plugs first

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Punctal Plugs
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Smartplugs
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Age-Related Cataract

• Definition
• Symptoms
• Examination
• Common Clinical Types

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Definition

• Change in clarity of human lens
• Commonly an ageing change a normal
  degeneration throughout life
• Cataract significant effect on vision
• Often optometrist unable to help with change of
  glasses

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Symptoms

• Rapid change in spectacle prescription myopic
  shift
• Blurring near and distance
• Glare
• No pain, watering, redness

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Examination

• Competent visual acuity
• Dilating drops
• Direct Ophthalmoscope

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Common Types

• Nuclear sclerosis
• Cortical
• Posterior Subcapsular

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Anatomy
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Nuclear
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Cortical
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PSCLO
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Acute Angle Closure(Glaucoma)

• Incidence increases with age peak 70 years
• 0.1 incidence in UK Effect of cataract surgery
• 3/4x commoner in females
• Associated with hypermetropia (long sight)
• Normally unilateral

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Cause

• Shallow anterior chamber with narrow angle
• Pupil block
• Angle occlusion with rapid severe elevation of IOP

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Symptoms

• Intermittent discrete episodes of aching of eye
  with blurring/halos
• Semidilated pupil dim light
• Evening onset
• Goes away after sleep
• Full attack
• Increasing intensity pain - vomiting/distress
• Progressively severe blurring
• Will not resolve without treatment

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Signs

• Red eye circumciliary injection
• Fixed unreactive semidilated oval pupil
• Hard very tender eye with high IOP