Classic view for primary eye care team

1. AN EYEFOR AN EYE
APPROACHING THE RED EYES
LimitationS and ExpectationS
AHMAD ZULFAHMI SHA’ARI
OPHTHALMOLOGY DEPARTMENT

2. OUTLINE
 EYE ANATOMY
 APPROACHING THE EYES
 WHEN TO REFER OPHTHALMOLOGIST
 TRAUMA CASES
 NON TRAUMA CASES
 COMMON MISINTERPRETATIONS

3. ANATOMY
 Lid
 Conjunctiva
 Cornea
 Sclera
 Pupil
 Lens
 Vitreous
 Fundus

4. A CASE…
 A 60 years old malay male presented with re redness x
2/7 with bov and having occasionally headache &
nauseac, went to GP and KK 2-3 times treated with
conjunctivitis. Given topical antibiotics and painkiller
through out the course.
 After 2/52 of presentation, came back to KK & they
decided to refer to ophthalmologist for persistent
conjunctivitis.
 Assessment then reveal she had acute glaucoma which
then treated with topicals antiglaucomas and peripheral
iridectomey.
 Misdiagnosed? What’s missing?
11/12/2019

5. HISTORY
 Unilateral or
bilateral?
 Pain?
 Discharge?
 Photophobia?
 Floaters/ Flashes
of light?
 History of
Trauma / eye
surgery?
 SYSTEMIC
ILLNESS/ MEDS
 OCCUPATION
 Contact lens
wear?
 Using ocular
medication?
Topical or oral?
STEROIDS?

6. EYE EXAMINATION
 1. Visual Acuity Chart eg. Snellen
 2. Torch light ; RAPD, Anterior chamber depth
 3. Cotton bud – to evert eyelids
 4. Direct Ophthalmoscope – to visualise the fundus
 5. Magnifying glass/simple magnifying loupes – visualise the anterior
structures
 6. Local anaesthetic drops
 7. Fluorescence strip – screen for abrasion/laceration/ AC perforation

7. RAPD
-RELATIVE AFFERENT PUPILLARY DEFECT-
Define:
A condition when pupils respond differently to light
stimuli shone in one eye at a time due to unilateral
or asymmetrical disease of the retina or optic nerve
11/12/2019

8. 11/12/2019

9. 11/12/2019
- EXPLAINED TO PATIENT YOU’LL
COME NEAR FACE.
- RE TO RE, LE TO LE
- GET A CHAPERONE
- DIM/ OFF LIGHT IN THE ROOM

10. RED REFLEX
11/12/2019

11. DIRECT OPHTHALMOSCOPE
11/12/2019

12. 11/12/2019

13. WHEN TO REFER TO
OPHTHALMOLOGIST
11/12/2019

14. TRAUMA (PENETRATING)
 GLOBE PERFORATION
 CORNEAL LACERATION
 EYELID MARGIN LACERATION
 IRIS/UVEAL PROLAPSE
 INTRA-OCULAR FB (IOFB)

15. TRAUMA (BLUNT)
BLOW OUT FRACTURE
HYPHEMA
CHEMICAL INJURY/ VENOM SPLASH

16. TRAUMA (MILD)
11/12/2019
CORNEAL ABRASION
CORNEAL FOREIGN BODY

17. NON-TRAUMA
ACUTE GLAUCOMA
 Sudden increase IOP caused by
impaired outflow facility secondary
to appositional or synechial closure
of the anterior chamber drainage
angle.
 Conjunctiva: ciliary injected
 Cornea: edematous (hazy)
 Anterior chamber : shallow
 Pupil :not reactive, mid-dilated
11/12/2019

18. CONJUNCTIVITIS
11/12/2019
INFECTIONS
CORNEAL ULCER / HYPOPYON
ORBITAL CELLULITIS
PAINFUL EYE POSTOPERATIVE INTRAOCULAR SURGERY
(Endophthalmitis)

19. PAEDS
NEONATAL CONJUNCTIVITIS
WHITE PUPIL IN CHILDREN
(LEUKOCORIA)
11/12/2019

20. All presentations of
SUDDEN PERSISTENT
LOSS OF VISION
require an URGENT
ophthalmology
referral

21. ACUTE VISION LOSS
Central Retinal Artery Occlusion
 Causes
 Thrombosis, embolus, giant cell arteritis,
vasculitis, sickle cell disease, trauma
 Preceded by amaurosis fugax
 Painless vision loss
 RAPD +ve
 Pale fundus with narrowed arterioles
and segmented flows (boxcars) and
bright red macula (cherry red spot)

22. 11/12/2019

23. 11/12/2019

24. RETINAL DETACHMENT
11/12/2019

25. COMMON
MISINTERPRETATIONS
11/12/2019

26. ACUTE GLAUCOMA VS CONJUNCTIVITIS

27. CORNEA: ULCER VS SCAR
 Scar VS ulcer
 Abrasion VS Laceration

28. CORNEA: ABRASION VS LACERATION

29. FOREIGN BODY VS IRIS PROLAPSED

30. A CASE…
 A 60 years old malay male presented with re redness x
2/7 with bov and having occasionally headache &
nauseac, went to GP and KK 2-3 times treated with
conjunctivitis. Given topical antibiotics and painkiller
through out the course.
 After 2/52 of presentation, came back to KK & they
decided to refer to ophthalmologist for persistent
conjunctivitis.
 Assessment then reveal she had acute glaucoma which
then treated with topicals antiglaucomas and peripheral
iridotomy.
 Misdiagnosed? What’s missing?
11/12/2019

31. TAKE HOME MESSAGE:
OPTHALMOLOGIST REFERRAL
 Traumatic injury to the eye
 Acute Loss of vision
 Extreme eye pain not explained by pathology
 Keratitis/ Corneal ulcer
 Suspected uveitis/ glaucoma
 Chemical injury to the eye
THANK YOU

32. REFERENCES
Ophthalmology Referral Guide For GPs
Common Eye Condition Management, Moorfields Eye Hospital NHS
Foundation Trust
Eye Emergency Manual: An Illustrated Guide, New South Wales
Department of Health