14: OPHTHALMOLOGY

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CHAPTER 14 OPHTHALMOLOGY

The discharging eye

Eyelid problems

The acute red eye

The painful eye

Sudden visual loss

Progressive visual loss

Chronic glaucoma

THE DISCHARGING EYE

Eyes water as a result of either excessive tear production or inadequate tear drainage.

Management

For a chronically sticky eye in a baby, show the parents how to massage the lacrimal duct with gentle pressure from the index finger over the medial palpebral fold twice daily. Only use antibiotic eyedrops if the eye is red. Regular swabbing with moistened cotton wool helps. Refer for duct probing under anaesthetic if there has been no improvement by 6 months of age.

Eyelashes in the tear duct can be easily removed with fine forceps.

Refer the patient with an ectropion, entropion or ingrowing eyelash for corrective surgery. Avoid antibiotic drops or ointment unless obvious conjunctivitis is present.

THE DRY EYE

Dry eye is a symptom that has many causes. The patient may mean gritty, sore, irritating or even painful eye (see p. 230).

Management

• Give antibiotic eyedrops for suspected conjunctivitis.

• Hypromellose eyedrops prn are often the most useful treatment for the chronically dry eye.

• Manage any underlying disease as appropriate.

• Refer for eye surgery in cases of ectropion and entropion.

EYELID PROBLEMS

STYE

Styes are very common. They are infected eyelash roots and produce a red, painful swelling at the lid margin.

Management

Advise regular warm steaming. Consider antibiotic eyedrops, e.g. chloramphenicol or fusidic acid.

MEIBOMIAN CYST (CHALAZION)

This is less common than a stye and produces a red, uncomfortable eyelid swelling at a distance from the lid margin.

Management

For the acute infection advise regular warm steaming. The cyst usually bursts through the conjunctival surface of the eyelid after a few days.

If the problem is recurrent or if the cyst remains, consider referral to an ophthalmologist for incision and curettage.

BLEPHARITIS

Blepharitis is chronic inflammation of the lid margins. It gives the eyes a sore, tired appearance, with red lid margins.

Management

• Advise the patient to avoid rubbing the eyes and pay attention to cleaning the lid margins carefully with warm water.

• Baby lotion or diluted baby shampoo wiped over the lid margins with a cotton wool bud often helps. Consider treating exacerbations with a topical antibiotic, e.g. Fucithalmic ointment.

• Treat any associated seborrhoeic dermatitis (see p. 137).

SQUINT

A squint is a misalignment of the visual axes of the two eyes. It is normal in very new babies, until they are old enough to focus on near objects.

Diagnosis

History

• When does the child have the squint (e.g. when tired)?

• Ask if there have been any developmental problems.

Examination.

Attempt to confirm the squint, as prominent epicanthic folds often give the false impression of a squint.

The corneal light reflex.

With the child looking at the light of a pen torch from a distance of about half a metre, the reflection of the light is symmetrical in each eye in the non-squinting child.

The cover test.

Get the child to look at a small toy. Cover one eye while observing the other eye. If the uncovered eye moves to take up fixation on the toy, the child probably has a squint.

The red reflex.

In babies check for the rare conditions retinoblastoma, retinitis pigmentosa and cataract using the red reflex. Observe the eyes through the ophthalmoscope from a distance of 20 cm. The normal eye has a uniformly red reflection in the middle of the pupil. Any abnormality of this reflex is suspicious.

If there is an abnormal red reflex, refer immediately.

Management

• If the squint is confirmed, routine referral to the ophthalmology outpatient department is indicated.

• If a squint is not confirmed, refer if the history is convincing. The latent squint may appear only when the child is tired. Otherwise reassure the parents and offer to review the patient in 6 months.

• Reassure the parents that most squints can be corrected without surgery, e.g. by the use of patching or spectacles.

THE ACUTE RED EYE

There are many causes of red eye, even in general practice. The lists below give the principal distinguishing features.

• Most red eyes in general practice are not painful.

• The acute, painful, red eye usually needs urgent referral to ophthalmology.

• The very painful, red eye should be referred immediately.

CONJUNCTIVITIS

Conjunctivitis is the most common eye condition seen by GPs. It is usually seen in the context of an upper respiratory tract infection or hay fever. It is mild and self-limiting.

Management

• The eye should be kept clean. Hygiene advice is important. Treat with topical antibiotics, e.g. chloramphenicol drops qds, only if the symptoms have not improved after a few days.

• If there is no response, a swab of the discharge can be sent for microscopy, culture and sensitivities. At the same time, the treatment can be changed to fusidic acid eyedrops bd for a further week.

• In hay fever, the conjunctivitis is likely to be allergic, and treatment with antihistamine tablets, e.g. loratadine 10 mg od, or eyedrops, e.g. sodium cromoglycate qds, should be tried initially.

• If there is no response, consider referral.

Children with conjunctivitis do not need to be excluded from school or nursery.

HERPES ZOSTER INFECTION

• Not uncommon.

• Periorbital vesicular rash.

• Watering eye.

Management

Refer urgently, to exclude a dendritic ulcer. Treat with oral aciclovir.

SUDDEN VISUAL LOSS

Sudden loss of vision is an ophthalmological emergency and requires immediate referral to hospital.

ACUTE ANGLE CLOSURE GLAUCOMA

Diagnosis

History.

The patient has a severely painful red eye, may be vomiting, and complains of having seen haloes around lights.

Examination.

Examination reveals a cloudy cornea and a dilated pupil compared with the good eye.

Management

Instillation of 4% pilocarpine drops every minute for 5 minutes, then every 5 minutes will reduce the intraocular pressure. If available, an injection of 500 mg of acetazolamide iv will also help. Alternatively, a 250 mg acetazolamide tablet can be given if the patient is not vomiting. Arrange for the patient to go to hospital as soon as possible.

OTHER CAUSES

Cerebrovascular accident

The sudden onset of a homonymous hemianopia associated with a stroke is not unusual but can occasionally be the only neurological consequence of a posterior cerebral artery infarct. Referral is indicated for complete neurological assessment and rehabilitation (see p. 280).

Migraine

The visual changes accompanying a migraine attack are usually described as flashing lights, blurred vision or spots or zigzags, rather than loss of vision. If visual loss is reported as a presenting complaint for the first time, even in the presence of a migrainous headache, it is wise to discuss the case with the duty ophthalmologist.

PROGRESSIVE VISUAL LOSS

Children and young adults with progressive visual loss should be referred to an ophthalmologist. The causes in this group include:

• refractive error

• amblyopia of disuse

• diabetic retinopathy

• inherited retinal degeneration (e.g. retinitis pigmentosa)

• posterior uveitis

• pituitary tumour.

Adults with gradual blurring of the vision can be encouraged to see an optician first. They are most likely to need only spectacles.

The commonest causes of progressive visual loss in the elderly

• Refractive error.

• Senile macular degeneration.

• Chronic open-angle glaucoma.

• Hypertensive retinopathy.

Management

Referral to an ophthalmologist is indicated in most cases of visual loss. The timing of the referral depends on a number of factors, including the suspected cause and the patient’s need to try and recover some of the lost vision (see cataract, below).

Registration of a patient as partially sighted or blind is the statutory duty of the consultant ophthalmologist, not the GP.

Advice.

Benefits and aids for the partially sighted are many. Refer the patient to the social worker for the blind unless this has already been done.

Inform the patient of the existence of the Royal National Institute for the Blind (see p. 358) and any local clubs for the blind and partially sighted.

CATARACT

Cataract, or lens opacity, affects approximately 25% of the population in the 65–75-year age range.

CHRONIC GLAUCOMA

Chronic open-angle glaucoma is usually suspected by finding a raised intraocular pressure, cupping of the optic discs or peripheral visual field loss on charting. These changes are usually detected by the optician on routine eye testing.

Referral to the ophthalmology outpatient department is indicated.

Confirmed cases are followed up in outpatients. Treatment usually consists of eyedrops to either reduce intraocular pressure or facilitate anterior chamber drainage. Occasionally, surgery is indicated (iridocentesis).

Issues for the GP include:

• Family members are at increased risk of chronic glaucoma.

• Repeat prescribing of eyedrops.

• Beta-blocker eyedrops can have systemic effects in e.g. asthma.

• Management of progressive visual loss (see pp. 233–234).

FLOATERS

Floaters are small, black spots, seen by the patient to be floating in front of the eyes. They are very common and patients need reassuring that there is likely to be nothing wrong with their eyes.

The fortification spectra of migraine may be described as black spots, but these are usually followed by the headache and are temporary.

Management

Nothing need usually be done, other than to reassure the patient that the condition is benign and usually self-limiting.

If the floaters are described as large, dark blobs which appear suddenly and are associated with flashing lights, the cause may be retinal detachment and the patient should be referred immediately.

Occasionally the patient may have a cataract (see p. 234).

Related

Churchills Pocketbook of General Practice