Eyes

1. Eyes
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2. You are not alone!
A very popular topic
How much time at medical school?
What do the acuity numbers mean!
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3. Special history
One or both?
What disturbance of vision?
Rate of onset?
Any blind spots?
Any associated symptoms e.g.
floaters? flashing lights?
Exactly what is worrying the patient.
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4. Contact lens use?
Myopia? (increases risk of retinal
detachment 10 fold)
Any family history? (FH of
glaucoma in a 1st degree relative
gives you a 1/10 lifetime risk, or
squint)
Any history of diabetes,
hypertension or connective tissue
disease? Brought to you by

5. Examination
Snellan chart, 3m or 6m, simple text for near
vision,
Pinholes
Fields, remember red and the quality of the red,
simple 4 quadrant testing.
Pupils: a bright torch and magnifying glass
Squint
Movements
Opthalmoscopy: Start at 10, red reflex?, green
filter enhances blood vessels, dilate prn, risk of
acute closed angle glaucoma remote. Brought to you by

6. Clinical classification
Red eye
Lids and tears
Slow visual loss in the quiet eye
Trauma
Squints, new and congenital, rare
movement disorders
 …..(then a rare specialist rag bag)
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7. Red eye
Conjunctivitis
Commonest, an uncomfortable red eye.
Bacterial
 Discomfort. Purulent discharge. Spreads
from one eye to the other. Vision normal.
Uniform engorgement Chloramphenicol
first choice (?)
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8. Conjunctivitis
Viral
Often with an URTI. Gritty.
Discomfort. Watery discharge. May
last many weeks.
Photophobia. Small corneal opacities
may develop. Prolonged (often
adenoviral) may need specialist
therapy with steroids.
Chloramphenicol to prevent 2nd
infection.
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9. Conjunctivitis
Chlamydia
 Mucopurulent, cornea inflamed, visual loss. Often
with STD. Permanent damage possible, topical
and? systemic tetracyclines. Refer.
Infants
 Less than one month is notifiable disease - any
cause. May lead to scarring and permanent
damage. Refer most.
Allergic
 Itching and discomfort. Chemosis and visual
acuity loss possible. Papillae and if big
cobblestones. Cromoglycate may take days to
start to work if bad. Brought to you by

10. Episcleritis / scleritis
Red sore eye. No discharge. Localised
(viz. conjunctivitis=generalised)
inflammation.
Episcleritis usually self limiting and
idiopathic, no treatment needed.
Scleritis often with CT diseases,
dangerous (perforation possible)
Refer.
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11. Corneal ulcers
 Any infection, Abrasion, topical steroids, contact
lens use.
 PAIN. - Except zoster
 May be general or localised inflammation.
 Must stain. Should evert upper lid to exclude a
sub tarsal FB
 ?Hypopyon - pus in anterior chamber.
 Refer most (except small abrasions - but refer if
big or longer than 36 hours)
 Remember recurrent abrasion syndrome.
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12. Anterior uveitis
 The uveal tract. So iritis, iridocyclitis and
anterior uveitis are synonyms.
 At risk: HLA-B27, CT diseases, past attacks,
juvenile arthritis, sarcoid.
 PAIN, then photophobia then visual loss.
 Ciliary flush. As it gets worse the pupil gets
small and reactions get sluggish, hypopyon,
keratitis (back of cornea). These markers of
it getting worse are bad news.
 Refer all. Brought to you by

13. Acute closed angle glaucoma
Often starts in the evening.
Especially in those over 50 years.
Severe pain first. Impaired vision and
haloes around lights. May have
history of past episodes relieved by
going to sleep (the pupil constricts
during sleep).
Refer even if attack spontaneously
resolves. Brought to you by

14. Lids and tears
Chalazion
= meibomnian cyst. In the lid. Warm
compresses and chloramphenicol.
Persistent - incise.
Recurrent: ? DM, ? blepharitis, ?
roseacea.
Can cause astigmatism from
pressure.
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15. Stye
An infection of lash follicle. May
be head of pus - nick with needle.
Or warm compresses and
chloramphenicol.
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16. Marginal cysts
Non infected cysts from sweat or
sebaceous lid glands, if a problem
can often be simply treated with a
nick with a needle - small.
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17. Blepharitis
Common, underdiagnosed. Persistently
sore eyes. Gritty. Often with chalazions or
styes. Inflamed lid margins, crusts, may
have inflamed lids.
 Associated with psoriasis, eczema and
roseacea.
 Keep clean, antibiotic
ointment[tetracycline], artificial tears ?
oral tetracyclines
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18. Acute dacrocystitis
Medial inflammation over lacrimal
sac. Refer, systemic therapy and
topical urgently.
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19. Orbital cellulitis
 Life threatening and blinding. Usually
from sinuses. Especially important in
children who may become blind in hours.
Unilateral swollen lids which may not be
red.
 The patient is ill, there is tenderness over
the sinuses, restricted eye movements.
ADMIT
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20. Ectropion
Watery eye.. Laxity from age or nerve
palsy. Ointment and refer for LA operation
to correct.
Entropion
Common especially in the elderly.
Scarring from the lashes.
 Often results from blepharitis or chronic
conjunctivitis
 Refer Brought to you by

21. Ingrowing lashes
Damage to lids. May be
removed but will often need
electrolysis or cryocautery to
prevent recurrence.
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22. Watering eyes
Differential diagnosis.-
your homework!
Dry eyes
Common,
Remember to treat associated
blepharitis
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23. Sudden visual loss
An easy list really as
they all need
specialist
assessment!
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24. Retinal detachment
 Floaters, photopsias, the shadow or curtain
across the sight.
Optic neuritis
 More women, pain on moving the eye,
central scotoma
Posterior vitreous detachment
 Aged 50+, flashing lights, floaters
Vitreous haemorrhage
 Floaters, red haze may be present. Red
reflex absent.0
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25. Disciform macular degeneration
•Sudden disturbance of central vision.
Vascular occlusions
•Field loss. Diabetes, hypertension
Migraine
•Youth, headache, zigzag lines,
multicoloured lights.
Cerebrovascular disease
•Elderly, bilateral loss.
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26. Slow visual loss
Refer to optician then ? refer.
Cataracts
Corneal opacities
Macular problems
Retinal problems
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27. Trauma
Refer !
Unless really trivial
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28. Squints
Refer
Remember the orthoptist
Can you do a cover test?
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