1: Recent onset of poor distance vision in a 17yo male (Condition 45):

2: Chronic Simple Glaucoma

3: Loss of Vision (Macular Degeneration)

4: HSV Keratitis

1;

You are working in a general practice. Your next patient is a 17-year-old

apprentice who is complaining of poor distance vision of recent onset. He

can no longer read notices, street signs, scoreboards etc. at a distance. He

says this is most inconvenient and is gradually getting worse. Both eyes are

affected. He has asked you if he may be short-sighted like his father and his

older brother. He wants to be tested to check for short-sightedness or any

other problems, to ask whether he will need glasses or contact lenses,

whether surgery can help and whether he should see an optician or an eye

specialist doctor.

Task

Examine patients eyes to exclude serious eye disease

Test VA using snellen chart and state your findings to

patient

Explain problem to the patient

Examination

Inspection:

o Size alignment/symmetrical, Eye lid: ptosis,

Conjunctiva: chemosis, redness, Cornea- ulceration,

abrasion, Sclera- jaundice, if theres any cataract/

pupils (if they are dilated, shape and size of the

pupils), anterior chamber- blood, pus, proptosis

PEARL:

Ophthalmoscopy:

o Red reflex (if red reflex absent Cataract)

o Posterior chamber,

o Retina for any detachment, exudates (macular

degeneration, diabetic and hypertensive

retinopathy), hemorrhage, DM HTN),

o Optic disc- Papilledema, optic atrophy, Macula

(Exudates Drusens- dry or wet new blood

vessels formed between choroid and retina in

macular degeneration),

o Feel the increase of pressure-Glaucoma -

tonometry, Any degeneration

Visual Acuity: 6m/20ft 6/18

When to diate the eyes find it out from tutor ???

o Visual Fields

o Eye movements: for any weakness of muscles,

look for any diplopia. Accomodation

o Pin hole test: If the vision is improving?

Mx:

Send the patient to the eye Specialist/Optometrist:

Prescription Concave lens

Driving: 6/12

2:

Your next patient is a 45-year-old female who complains of difficulty in

vision for the last couple of months. The VA showed 6/18 in both eyes

and did not improve with pinhole test.

Task

History

o (gradually on both eyes; painful; I have to turn my

head to see the signs; diabetes 7-8 years, well-

controlled; no allergies; non-smoker, occasionally

drinks alcohol)

Examination

o (general appearance normal, BMI normal;

peripheral vision affected; optic disc

cupping/papilledema)

Diagnosis and management

Additional Features:

Screening:

o adults >40 years 2-5yearly; start early at - 30

years and 2 yearly if with family history

Treatment:

o timolol or betaxolol drops BD; latanoprost,

pilocarpine, dipivefrine, acetazolamide

DDx:

Macular degeneration

Visual defects due to pituitary tumor

Cataract

Glaucoma

Optic neuritis

Risk factors

FHx of glaucoma

Myopia

Migraine

DM

Hypertension

Eye injuries

Hx:

Is it affecting one or both eyes? Is it for the first time?

Did it happen suddenly or gradually? (retinal detachment

is sudden)

Is it progressing?

Any vision problems at night or during the day?

Have you noticed that you bump into people quite often?

Do you need to turn your head in order to see objects on

road while driving?

Any problem in recognizing faces? Any problem with

central vision (MD)? Can you read properly?

Have you noticed any halos around the eye? (mainly in

cataract, sometimes in glaucoma)?

Are you wearing contacts or spectacles? Have you

noticed that you frequently need to change them? Is it

painful?

Any N/V? Any history of eye trauma?

Any redness or watering from the eyes? Any headaches?

Have you noticed any discharge from your nipple -

prolactinoma?

Any flashes or floaters?

Any tingling/numbness or weakness in any part of the

body?

Any history of DM or HTN? Do you have any history of

asthma? FHx of eye conditions? SADMA?

PEx:

General appearance

Vital signs

Eye: Inspection:

o Discharge, redness, discoloration, ptosis, shape

and size of pupil;

o PEARL; EOM extraocular muscles; visual

fields;

o Funduscopy without dilating the pupils

because I suspect glaucoma (optic disc

cupping >30%); tonometry (10-20)

Management

o Most likely you have a condition called glaucoma

which is due to an increase in fluid production or

due to decrease in drainage causing increased

pressure of the eye. Because the eye is a closed

organ and fluid cannot escape properly, it can

cause damage to the nerves. It is a common

condition but is potentially risky if its not

managed early.

o Do not worry. We will take good care of you.

o To avoid getting glaucoma, people should have

regular eye checkup especially if they have risk

factors such as DM, hypertension,

nearsightedness.

o At this stage, I will refer you to the

ophthalmologist. He will examine you and

probably start you on medications such as timolol

(increase drainage 1 drop every 30-60 mins)

and pilocarpine (1 drop every 5 minutes -- open

angle) drops.

o The specialist might decide to give

acetazolamide if he deems it necessary.

o Once stable, the long-term management is laser

surgery (iridotomy) wherein we make holes in the

iris.

o Please do not drive

o Reading material.

o Review and regular follow-up.

3:

Your next patient in GP practice is a 60 year old male who

complained of visual loss and difficulty reading newspaper over 6

months. He was sent by district nurse whos concerned about his

reduced visual acuity.

Task:

History

o (blurred for 2 months, difficulty recognizing faces;

progressive; not driving now, no headache, diabetic , no

meds, alcohol socially, no smoking)

Physical examination

o (no discharge, redness, pain, normal pupil size, +Drussen

on funduscopy and elevation of macula)

Diagnosis and management

DDx:

Macular Degeneration

Cataract

Glaucoma

Tumor

Presbyopia

Retinopathy (DM/HTN) - exudates

Hx:

I understand you have problem with your vision.

When did it start? How is it progressing? Is it affecting one or both

eyes?

Do you have difficulty recognizing faces? Is the visual problem

involving all of the visual field, center or periphery?

Do lines appear wavy when reading newspaper?

Does your visual problem get better (presbyopia) or worse with

light (cataract)? Any halos around?

Any flashes or floaters? Any pain or redness in your eyes? Do

you wear glasses?

Does it get better when you wear glasses?

When was the last time you got it checked? Any eye discharge?

Any headaches?

Hows your general health? Any significant medical or surgical

problems? Are you on any medications? Do you get your eye

checked regularly? Any trauma in your eyes?

Any FHx of similar condition or eye problems? SADA?

PExPEx:

General appearance

Vital signs

Eye:

Inspection:

o eyelid, sclera, conjunctiva, cornea, ptosis, problem

with size or shape of pupil

Palpation:

o orbital tenderness

Pupillary reflex and red reflex (lost in cataract)

Visual acuity and pinhole

Visual fields

Extraocular movements

Funduscopy

Tonometry

Amsler grid test

Chest, heart, abdomen

Mx:

Most likely you have a condition called macular degeneration.

Have you heard about it? It is common in this age and is due to

some changes in the part of your eye called macula.

Draw diagram: retina is back part where you receive images and

center is called macula which is responsible for central vision.

With age, this area undergoes some degenerative changes and

there are some risk factors including increasing age, family

history, smoking and poor diet, cardiovascular problems,

Caucasian race.

I will refer you to the ophthalmologist who will do the amsler grid

test and it is very important to determine the type of MD. This will

be assessed by the ophthalmologist. If it is a wet MD, which is

less likely, he might do further tests such as fluorescein

angiography and laser at a later stage. If it is dry which is more

common, all we need to do is regular followup.

You will need to have lifestyle modification. Good diet, regular

exercise, and stop smoking. Take Vitamin A, C, E and zinc which

can be helpful. Unfortunately, there is no treatment for it, but we

can slow the progression.

Reading material.

Red flags: Sudden loss of vision, redness, pain

Features:

Leading cause of blindness for the over 50 population in western

world, more common in increasing age, in patients with myopic,

and may run in families

Progressive disease

Always painless

Dry: most common (95%)

Central Scotomas, Lines appear wavy

Problems recognizing faces

Clinical Features:

distortion of vision

sudden fading of central vision, eventual loss of central vision

Early: yellow colored deposits (Drusen) in the early/initial

Later: hemorrhages and geographic atrophy

Wet/Choroidal Neovascularization:

o Caused by neovascular membrane that develop

under the retina with macular area and leak fluid or

blood (Sub-retinal blood or lipid Pinkish-yellow sub-

retinal lesion with fluid)

o Sudden deterioration of vision due to formation of

new blood vessels which are fragile, this leads to

leaking.

o More serious than dry Macular Degeneration.

o Metamorphopsia is initial smptoms amsler grid

distorted vision with no central dot

o Most lesions are not visible clinically

Diagnostics:

Fluroscein angiogram

Amsler grid changes

Treatment:

Dry:

o Vitamin A/C/E + zinc + antioxidants

o Lifestyle modification

Wet:

o Laser coagulation

o nti-VEGF injection (vascular endothelial growth factor)

_

4:

David aged 27 years complains of a red right eye for the last few

days. He says it feels irritated and that light bothers him. He feels his

vision is a little worse than normal on the irritated eye. He wears

fortnightly disposable contact lenses and has done so for the last four

years. He has no significant past medical or ophthalmic history

Task:

Focused history

Examination findings from examiner:

o (VA: R: 6/12, L:6/6, right has red eye without discharge,

no lid swelling, ophthalmoscopy normal; PEARL, eye

movement, accommodation normal)

Probable diagnosis and treatment advise

DDx:

o Uveitis: usually associated with CTDs. connective tissue

diseases

o Keratitis: especially HSV (usually dendritic ulcers)

o Foreign body: ask for patients profession

History:

o Have you noticed blurring of vision?

o Ever been in close contact with others with same

condition?

o Have you had a cold or running nose recently? Do you

wear contact lenses? Can you recall scratching/injuring

your eye?

o What were you doing at the time you noticed trouble?

o Have you been putting any drops, ointments, or

cosmetics around the eye?

o Do you suffer from hay fever?

o Do you have any problems with your eyelids?

o Had your eyes been watering for sometime beforehand?

Have you had any other problems?

o Have you been exposed to arc welding?

Ex:

o Eyes: visual acuity, pinhole test, pupils, ocular

tension/tonometry (21-22), fluorescein staining,

funduscopy

o Eye lids, cornea and conjunctiva, eyelid eversion

o Cranial nerve examination

Features

o Produces follicular conjunctivitis

o 70% associated lid or corneal ulcers/vesicles

o Dendritic ulceration highlighted by fluorescein staining

diagnostic

o Antigen detection or culture may allow confirmation

Tx:

o Eye hygiene

o Acyclovir 3% ointment 5x a day x14 days or for at least 3

days after healing

o Atropine 1% 1 drop , q12 hourly, for duration of treatment

will prevent reflex spasm of the pupil (specialist

supervision)

o Debridement by a consultant, Refer to ophtha:

especially if central ulcer; if peripheral may treat but must

review after 24-48 hours.

o Do not dilate eye (as GP)!!!

o May result in blindness if not treated properly.

RED EYE PAIN PHOTO- PHOBIA

DIS- CHARGE

PUPIL

VISION

Conjunc- tivitis

Discomfort

+ (viral) - (bact.)

Watery Purulent

N N

Keratitis + + Watery N BOV blurring of vision

Iritis/ Uveitis

+ (radiates to brow, ear, nose)

+ Watery Constricted, irregular

BOV

Acute glaucoma

+ severe, N/V

+ - Fixed, dilated pupil (-) light reflex

Impaired