When to Care When to Care –– When to ReferWhen to Refer

Acute Eye Problems in the Acute Eye Problems in the CommunityCommunity

Frank MunroFrank Munro

TodayToday’’s Talks Talk

nn Acute Eye ProblemsAcute Eye Problems

nn Burden of Disease Burden of Disease –– Making a DifferenceMaking a Difference

nn Shifting the Balance of Care?Shifting the Balance of Care?

nn What do I do now What do I do now –– Could I do more?Could I do more?

nn Clinical Decisions MakingClinical Decisions Making-- When to Care When to Care –– When to ReferWhen to Refer

Clinical decision MakingClinical decision Making

nn DiagnosisDiagnosis

nn ManagementManagement

nn Demonstrate CompetenceDemonstrate Competence

nn Working within scope of practiceWorking within scope of practice

nn DO NO HARM!DO NO HARM!

BirthBirth

DeathDeath

The Challenge!The Challenge!

Scope of PracticeScope of Practice

Where am I?Where am I?Ant / Post BlepharitisAnt / Post Blepharitis

Bacterial Bacterial conjunctivitisconjunctivitis

Microbial KeratitisMicrobial Keratitis

Retinal Retinal DetachmentDetachment

Anterior Anterior UveitisUveitis

Dry EyeDry Eye

CataractCataract

RetinoschissisRetinoschissis

‘‘WetWet’’ ARMDARMD

Dry ARMDDry ARMD

GlaucomaGlaucoma

Allergic/Toxic ConjunctivitisAllergic/Toxic Conjunctivitis

Ischaemic Optic Ischaemic Optic NeuropathyNeuropathy

Corneal FBCorneal FB

Marginal Marginal KeratitisKeratitis

EpiscleritisEpiscleritis

ScleritisScleritis

EndophthalmitisEndophthalmitis

Conjunctival HgeConjunctival Hge

Corneal AbrasionCorneal Abrasion

InclusionInclusion

Chemical BurnsChemical BurnsNeoplasiaNeoplasia

CellulitisCellulitis

ENTRYENTRY HESHESADVANCEDADVANCED

Viral Viral CorneaCornea

PVDPVD

Ping / PterygiumPing / Pterygium

Trichiasis /EpilationTrichiasis /Epilation

Keratitis/ KeratopathyKeratitis/ Keratopathy

ChalaziaChalazia

KerataconusKerataconus

UV BurnUV Burn Penetrating Penetrating InjuryInjury

UveitisUveitisint/postint/post

CornealCornealDystrophyDystrophy

Corneal ErosionCorneal Erosion

Sub tarsal fbSub tarsal fb Viral ConjunctivitisViral Conjunctivitis

EXPERTEXPERT

GIES Patient CategoriesGIES Patient Categories

CategoryCategory NoNo %% CategoryCategory NoNo %% CategoryCategory NoNo %%

NADNAD 112112 9.69.6 BlepharitisBlepharitis 3939 3.43.4 OcularOcular 1616 1.41.4

Dry EyeDry Eye 111111 9.69.6 GlaucomaGlaucoma 3737 3.23.2Anterior Anterior uveitisuveitis 1515 1.31.3

ConjunctivitisConjunctivitis 9090 7.87.8 RetinalRetinal 3535 3.03.0 FloatersFloaters 1414 1.21.2

DiabetesDiabetes 7272 6.26.2 Tear duct etcTear duct etc 3131 2.72.7 CystCyst 1212 1.01.0

CataractCataract 6868 5.95.9 EpiscleritisEpiscleritis 2929 2.52.5 EyelashesEyelashes 99 0.80.8

VitreoVitreo--retret 5252 4.54.5 KeratitisKeratitis 2222 1.91.9 OthersOthers 225225 19.419.4

Corneal/UlcerCorneal/Ulcer 4848 4.14.1 Visual disturbanceVisual disturbance 2020 1.71.7

PVDPVD 4444 3.83.8 MacularMacular 1717 1.51.5

Headache/migraineHeadache/migraine 4343 3.73.7 OcularOcular 1616 1.41.4 TotalTotal 11611161 100100

1

2

17

1

15

1

3

12

2

6

13

6

38

45

1109152

221185

1

181

1

9

6

152

9

1

1

216

4

4

1

220

1

156

110 21 6 5 11 5

11

2 21

462

AAU ACGAION ALLERARMD BELL'SBLEPH BLOW #C CYST C ULCERCAT CHE INJCL KERA CNOTWTCO ABRA CONJCSR DRY EYEEPISCL ERMFB GCAGL PERF H ACHEHSV KE HZOIOFB L CYSTM GRAVIS MACULOMARG K MIGRAINEMINOR TR MYO CNVNIL ONPAPILLO PCOPOST OP P SEP CELPSII PTERYPTOSIS PVDCRAO RC CO ERRD RET SCHIDR RUB GLACRVO SCHSCLER SINUSSLK TIATR AAU TR HYPHTRICHIA VIT HE

Grampian WalkGrampian Walk--In CasualtyIn Casualty

Top 10 Top 10 –– Eye Casualty!Eye Casualty!

1.1. Seasonal allergic conjunctivitisSeasonal allergic conjunctivitis2.2. Anterior UveitisAnterior Uveitis3.3. Infective ConjunctivitisInfective Conjunctivitis4.4. Corneal AbrasionCorneal Abrasion5.5. Dry EyeDry Eye6.6. EpiscleritisEpiscleritis7.7. Corneal FBCorneal FB8.8. HSKHSK9.9. Marginal KeratitisMarginal Keratitis10.10. PVDPVD11.11. TrichiasisTrichiasis

Contact Lens WorkContact Lens Work

CURRENT PRACTICECURRENT PRACTICE

THYGESONSTHYGESONS TRICHIASISTRICHIASIS

Meibomian

Dry Eye Allergy Infection Auto Immune

TraumaMechanical

Toxic Other

EvaporativeEvaporative NonEvaporative

NonEvaporative ChronicChronic AcuteAcute

VernalVernal

AtopicAtopic

GPCGPC

SeasonalSeasonal

PerennialPerennial

ViralViral

BacterialBacterial

InclusionInclusion

ParasiticParasitic

FungalFungal

EpiscleritisEpiscleritis

PemphigoidPemphigoid

UveitisUveitis

VasculitisVasculitis

ScleritisScleritis

Foreign Body

Foreign Body

InjuryInjury

TrichiasisTrichiasis

ChemicalChemical

MicrobialToxins

MicrobialToxins

AngleClosure

Glaucoma

AngleClosure

Glaucoma

RosaceaRosacea

EXTERNAL EYEEXTERNAL EYE

Clinical Decision MakingClinical Decision Making

COMMON CONDITIONSCOMMON CONDITIONSnot normally sight threateningnot normally sight threatening

REFERRALREFERRALsight threateningsight threatening

First AidFirst Aid+ +

Urgent ReferralUrgent Referral

ImmediateImmediateReferralReferral

PrescriptionPrescription&&

ReferralReferral

AlleviationAlleviation--

PalliationPalliation

PrescriptionPrescription&&

ManagementManagement

DIAGNOSISDIAGNOSIS

Acute glaucomaAcute glaucomaMicrobial keratitisMicrobial keratitis Anterior uveitisAnterior uveitis Corn. abrasionCorn. abrasionBlepharitisBlepharitis

External Eye Disease Patient Pathway

Patient PresentationSuspected external

eye disease

Self Care Primary Care Secondary Care

Hospital Eye ServiceRefer to Hospital Eye Service for diagnosis and appropriate management

Condition not normally sight threatening

Optometrist/GPManagement

AdvicePrescription

Diagnosis uncertain

Optometrist/GP

If no response or there is concern

Optometrist / GPSuspected external eye

disease

Optometrist

Diagnosis

If sight threatening condition is identified

Common conditions that are not normally sight threatening (can therefore be managed in the community) for example:

Dry EyeCorneal AbrasionForeign bodiesBlepharitisEpiscleritisBacterial conjunctivitisConjunctival haemorrhageHordeolaAllergic, Toxic or Viral external eye conditions

Conditions that are normally sight threatening (should therefore be managed in secondary care) for example:

Anterior UveitisInclusionScleritisEndophthalmitisCellulitisMicrobial KeratitisAngle Closure GlaucomaChemical BurnsMarginal KeratitisNeoplasia

URGENT REFERRAL

Follow up & discharge

HistoryHistory

nn Age / SexAge / Sexnn General HealthGeneral Healthnn POHPOHnn Family HistoryFamily Historynn Recent HistoryRecent Historynn Onset / Duration / Symptoms stable or varying or Onset / Duration / Symptoms stable or varying or

regressingregressingnn Pain / redness /vision /photophobiaPain / redness /vision /photophobiann Presentation Presentation –– recurring/ / Intermittent?recurring/ / Intermittent?

What is the problem?What is the problem?

nn Pain v No Pain Pain v No Pain -- ? severity? severity

nn Red v WhiteRed v White

nn Visual Loss v Normal VisionVisual Loss v Normal Vision

nn ? Floaters / Photopsia? Floaters / Photopsia

nn Duration: Recent v Long Term Duration: Recent v Long Term

ExaminationExamination

nn VA /PinholeVA /Pinholenn PupilsPupilsnn Ocular MotilityOcular Motilitynn Anterior Segment Anterior Segment –– lids/lashes/red?/conj/cornea/anterior lids/lashes/red?/conj/cornea/anterior

chamberchambernn Internal Internal –– Lens/vitreous/retina/macula/optic nerveLens/vitreous/retina/macula/optic nervenn Applanation tonometryApplanation tonometrynn Slit LampSlit Lampnn Volk Volk –– DILATE!DILATE!nn GonioGonionn Visual Fields / confrontationVisual Fields / confrontation

Points to PonderPoints to Ponder

AdnexaLid Margin

Lashes

LimbusFornices

Upper Lower Tarsal

Plica

Follicles v PapillaeFollicles v Papillae

Follicles consist of hyperplastic lymphoid tissue & appear as elevated lesions encircled by blood vessels. Typically seen in reaction to topical agents, adenoviral & chlamydial disease

Papillae consist of hyperplastic conjunctival tissue full of inflammatory cells, normally seen in the palpebral conjunctiva. Associated with bacterial, and allergic conjunctivitis

External Eye ProblemsExternal Eye Problems

Dry EyeDry Eye

EvaporativeEvaporativeEvaporative TearDeficient

TearTearDeficientDeficient

Exposure

Meibomian Gland Disease

Other

CL

Lid ProblemSjogren’s

Primary

Secondary

Non-Sjogren’s

Lacrimal Disease

Abnormal Blink

Abnormal Aperture

Incongruous Surface

Glands Missing

(Distichiasis)

Ant / Post Blepharitis

Ocular Surface (Xerophthalmia)

Lacrimal Gland Obstruction

Primary

Secondary

Auto Immune Disease

Loss of Reflex Tearing

TestsTests

nn SchirmersSchirmers type1 with anaesthesiatype1 with anaesthesiatype 2 as 1 with nasal irritationtype 2 as 1 with nasal irritation

whatman no 41 filter paperwhatman no 41 filter paper< 10mm abnormal. < 3mm conculsive< 10mm abnormal. < 3mm conculsive

nn Tear Break Up timeTear Break Up timefluorscein stain tearfilmfluorscein stain tearfilm< 10 sec abnormal (average of 3 tests)< 10 sec abnormal (average of 3 tests)

Treatment overviewTreatment overviewTear secretorsTear secretors

Castor oilCastor oil

Meibomium lid diseaseMeibomium lid disease

Plugs or occlusionPlugs or occlusionWarm compressesWarm compresses

Moisture chambersMoisture chambers

Androgen dropsAndrogen drops

Artificial tearsArtificial tears

ImmunosuppressiveImmunosuppressive

Omega 3 fatty acidsOmega 3 fatty acids

Mucin secretorsMucin secretors

Mechanical StimulationMechanical StimulationHot CompressesHot Compresses

Lid MassageLid Massage

Lid ScrubsLid Scrubs

Lubricants Promote Healing!Lubricants Promote Healing!

Normal goblet cell density

They’re decreased in Dry Eye

Treated with preservative free lubricants Lubricant

preserved with Benzalkonium Chloride

Goblet Cell Density & Preservatives

Choices? Choices? Choices?Choices? Choices? Choices?

Avoid Avoid Benzalkonium Benzalkonium

Chloride!Chloride!

TreatmentTreatment retention retention –– Punctum PlugsPunctum Plugs

Plastic or silicone plugs Plastic or silicone plugs or Collagenor Collagen

Removable?Removable?

Can fall outCan fall outCan irritateCan irritateInfection?Infection?Can convert a dry eye to Can convert a dry eye to

a wet onea wet one

BlepharitisBlepharitis

AnteriorAnterior

PosteriorPosterior

BLEPHARITIS

1. Anterior• Staphylococcal• Seborrhoeic

• Meibomianitis• Meibomian seborrhoea

2. Posterior

3. Treatment

Staphylococcal blepharitis

•• Hyperaemia and telangiectasia of anteriorHyperaemia and telangiectasia of anteriorlid marginlid margin

•• Scarring and hypertrophy if longstandingScarring and hypertrophy if longstanding•• Scales around base of lashes Scales around base of lashes (collarettes)(collarettes)

•• Chronic irritation worse in morningsChronic irritation worse in mornings

Complications of blepharitis

Recurrent styes

Marginal keratitis Tear film instability

Trichiasis,madarosis,poliosis

Seborrhoeic blepharitis

•• Shiny anterior lid marginShiny anterior lid margin •• Greasy scales Greasy scales •• Lashes stuck togetherLashes stuck together•• Hyperaemia of lid marginHyperaemia of lid margin

Treatment of Blepharitis

1. Lid hygiene / Lid Scrubs1. Lid hygiene / Lid Scrubswith 50% baby shampoo / Suprannettes / Lid Carewith 50% baby shampoo / Suprannettes / Lid Care

2. Tear substitutes 2. Tear substitutes -- for associated tear film instabilityfor associated tear film instability

5. Systemic tetracyclines / Topical Steroids5. Systemic tetracyclines / Topical Steroids-- for severe blepharitisfor severe blepharitis

3. Warm compresses 3. Warm compresses -- to melt solidified sebum to melt solidified sebum in posterior blepharitis / ? Eyebagin posterior blepharitis / ? Eyebag

4. Topical antibiotics (Fucidic Acid) & steroids

HordeolaHordeola

Internal Internal

ExternalExternal

Chalazion (meibomian cyst)

Painless, roundish, firm lesion Painless, roundish, firm lesion within tarsal platewithin tarsal plate

May rupture through conjunctiva May rupture through conjunctiva and cause granulomaand cause granuloma

Acute hordeola

• Staph. abscess of meibomian glands

• Tender swelling within tarsal plate

• May discharge through skin or conjunctiva

• Staph. abscess of lash follicle and associated gland of Zeis or Moll

• Tender swelling at lid margin

• May discharge through skin

Internal hordeolum ( acute chalazion )

External hordeolum (stye)

Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision and curettage

1. Hot compresses / hot spoon bathing

OROR

2.

Trichiasis

•• Posterior misdirection of normal lashesPosterior misdirection of normal lashes

•• Most frequently affects lower lidMost frequently affects lower lid

Complications

•• Inferior punctate epitheliopathyInferior punctate epitheliopathy

•• Corneal ulceration and pannusCorneal ulceration and pannus

Signs

Treatment Options for Trichiasis

1. Epilation - but recurrence within few weeks

2. Electrolysis - but frequently repeated treatments required

3. Cryotherapy - for many lashes

4. Laser ablation - for few scattered lashes

5. Surgery - for localized crop resistant to other methods

Px AJ Phthiriasis palpebrarum

• Infestation of lashes by pubic crab louse and its ova (nits)• Typically affects children in poor hygenic conditions?

Treatment - removal, destruction and delousingLice gripping base of lashes Nits and empty shells adhere to base of lashes

ConjunctivitisConjunctivitisBacterialBacterial

ViralViralAllergyAllergyToxicToxic

Simple bacterial conjunctivitis

Crusted eyelids and conjunctival injection

Subacute onset of mucopurulent discharge

Treatment - broad-spectrum topical antibiotics eg Chloramphenicol

Signs

Adenoviral KeratoconjunctivitisAdenoviral Keratoconjunctivitis

Pharyngoconjunctival fever • Adenovirus types 3 and 7• Typically affects children• Upper respiratory tract infection• Keratitis in 30% - usually mild

Epidemic keratoconjunctivitis • Adenovirus types 8 and 19• Very contageous• No systemic symptoms• Keratitis in 80% of cases - may be severe

Adenoviral conjunctivitis

Usually bilateral, acute waterydischarge and follicles

Subconjunctival haemorrhages andpseudomembranes if severe

Treatment - Symptomatic / lubricants / NSAIDS eg Acular/? Steroids?

Signs of Adenoviral keratitis

•• Focal, epithelial keratitisFocal, epithelial keratitis •• Focal, subepithelial keratitis Focal, subepithelial keratitis •• May persist for monthsMay persist for months

Treatment - topical steroids if visual acuitydiminished by subepithelial keratitis

•• TransientTransient

Adult chlamydial keratoconjunctivitis• Infection with Chlamydia trachomatis serotypes D to K• Concomitant genital infection is common

Treatment - topical tetracycline and oral tetracycline or erythromycin

Subacute, mucopurulent follicular conjunctivitis

Variable peripheral keratitis

Allergic rhinoconjunctivitis• Hypersensitivity reaction to specific airborn antigens

Transient conjunctival oedema

• Frequently associated nasal symptoms

Transient eyelid oedema

• May be seasonal or perennial

Treat. H1 blocker (topical/systemic) / Mast Cell Stabiliser / Topical Steroids

Recurrent Corneal Erosion Recurrent Corneal Erosion

Recurrent Corneal Erosion Recurrent Corneal Erosion SyndromeSyndrome

Corneal defect might look Corneal defect might look like thislike this

Corneal epithelium basement Corneal epithelium basement membranemembrane

Basal cells Basal cells secretesecrete basement basement membrane, and have membrane, and have hemidesmosome attachments hemidesmosome attachments through the basement through the basement membrane to the underlying membrane to the underlying stromastroma

Corneal epithelium basement Corneal epithelium basement membranemembrane

Spontaneous

~ Anterior Basement Membrane Dystrophy (map-dot-fingerprint dystrophy)Traumatic

~ Branch/ twig in eye, childs fingernail

Ass

ympt

omat

ic

Recurrent Corneal Erosion Recurrent Corneal Erosion SyndromeSyndrome

Typical therapy once correctly Typical therapy once correctly diagnosed is often something diagnosed is often something

like:like:---- Lacrilube before going to sleepLacrilube before going to sleep-- Artificial tears eg Viscotears or Artificial tears eg Viscotears or

Systane as required through the Systane as required through the day day -- (For up to 3 (For up to 3 –– 6 months)6 months)

-- Silicone Hydrogel Bandage CLSilicone Hydrogel Bandage CL

Recurrent Corneal Erosion SyndromeRecurrent Corneal Erosion Syndrome

Alternative therapies for those who fail with Alternative therapies for those who fail with ““basic therapybasic therapy””::--

-- Mechanical Debridement/ Diamond Burr (to Mechanical Debridement/ Diamond Burr (to ““polishpolish”” Bownams Membrane)Bownams Membrane)

-- Anterior Stromal MicroAnterior Stromal Micro--PuncturePuncture-- Excimer laser phototherapeutic Excimer laser phototherapeutic ––

keratectomykeratectomy-- Nd:YAG laser treatmentNd:YAG laser treatment-- Superficial phototherapeutic keratectomySuperficial phototherapeutic keratectomy

Marginal keratitis • Hypersensitivity reaction to Staph. exotoxins• Often associated with Staph. blepharitis• Normally unilateral, transient but recurrent

Subepithelial infiltrate separated by clear zone

Circumferential spread Bridging vascularization followed by resolution

Progression

Treatment -- short course of topical steroids / topical antibiotic eg Fucidic Acid

Acne rosaceaAcne rosacea

Rosacea keratitis

Peripheral inferiorvascularization

Subepithelial infiltration Thinning and perforationif severe

• Affects 5% of patients with acne rosaeca• Bilateral and chronic

Progression

Treatment - topical steroids and systemic/topical tetracycline or doxycyline

EPISCLERITIS AND SCLERITIS

Episcleritis• Simple• Nodular

Anterior scleritis• Non-necrotizing diffuse • Non-necrotizing nodular• Necrotizing with inflammation• Necrotizing without inflammation

( scleromalacia perforans )

Posterior scleritis

Applied anatomy of vascular coats

Scleritis

•• Maximal congestion of Maximal congestion of deep vascular plexusdeep vascular plexus

•• Slight congestion of Slight congestion of episcleral vesselsepiscleral vessels

•• Maximal congestion Maximal congestion of episcleral vesselsof episcleral vessels

EpiscleritisNormal

•• Radial superficial episcleralRadial superficial episcleralvesselsvessels

•• Deep vascular plexus Deep vascular plexus adjacent to scleraadjacent to sclera

Simple episcleritis• Common, benign, self-limiting but frequently recurrent• Typically affects young adults• Seldom associated with a systemic disorder

Treatment • Lubricants• Topical steroids • Systemic flurbiprofen if unresponsive)

Simple sectorial episcleritis Simple diffuse episcleritis

Nodular episcleritis• Less common than simple episcleritis• May take longer to resolve• Treatment - similar to simple episcleritis

Localized nodule which can be moved over scleraLocalized nodule which can be moved over sclera Deep scleral part of slitDeep scleral part of slit--beam beam not displacednot displaced

Phenylephrine TestPhenylephrine Test

Diffuse anterior non-necrotizing scleritis

• Widespread scleral and episcleral injection• Relatively benign - does not progress to necrosis

• Oral steroids if unresponsiveTreatment • Oral NSAIDs

Nodular anterior non-necrotizing scleritis

Scleral nodule cannot be moved over underlying tissue

More serious than diffuse scleritis

On cursory examination resembles nodular episcleritis

Treatment - similar to diffuse non-necrotizing scleritis

Case SL Case SL -- History History

nn Age 56, femaleAge 56, femalenn Referred to GIESReferred to GIESnn Presented with painful red eyePresented with painful red eyenn Hx recurring red eyeHx recurring red eyenn Vision down R 6/7.5, L 6/5Vision down R 6/7.5, L 6/5nn Good General HealthGood General Healthnn Early cataractEarly cataractnn Health fundiHealth fundinn IOP 10mmHg, L 14 mmHgIOP 10mmHg, L 14 mmHgnn PresbyopicPresbyopic

Slit LampSlit Lamp

nn Perilimbal rednessPerilimbal rednessnn Mild painMild painnn BlurringBlurringnn Flare anterior chamber Flare anterior chamber

–– finefinenn Irreg pupilIrreg pupilnn GP for checks GP for checks ––

autoimmune diseaseautoimmune disease(idiopathic)(idiopathic)

TreatmentTreatment

nn Cyclopentolate 1%Cyclopentolate 1%nn Pred Forte 1%Pred Forte 1%nn Review 1 week (check Review 1 week (check

IOP IOP –– ? steroid responder)? steroid responder)nn After 2 weeks eyes quietAfter 2 weeks eyes quietnn Wean off steroidWean off steroid

for one week (Rebound for one week (Rebound effect)effect)

UVEITISUVEITIS

Anterior UveitisAnterior Uveitis

Int. UveitisInt. Uveitis

Posterior UveitisPosterior Uveitis

Systemic Association / Infectious / Idiopathic

71%71%

1%1%

5%5%

Causes of Anterior UveitisCauses of Anterior Uveitis

50% 50% HLAHLA--B27 B27 positivepositive

Ankylosing Ankylosing spondylitisspondylitis

Psoriatic Psoriatic arthropathyarthropathy

Reiters Reiters SyndSynd

ACUTE v CHRONICACUTE v CHRONIC

Juvenile Juvenile Idiopathic Idiopathic ArthritisArthritis

Fuchs Fuchs Heterochromic Heterochromic

CyclitisCyclitis

Secondary to Secondary to trauma or trauma or infection infection

Behcets Behcets diseasedisease

SarcoidosisSarcoidosis

Herpes Herpes Zoster Zoster Ophth.Ophth.

SyphilisSyphilis

Ulcerative Ulcerative colitiscolitis

Crohn Crohn diseasedisease

IdiopathicIdiopathic

SIGNSSIGNS

Treatment of Anterior UveitisTreatment of Anterior Uveitisnn Pupil dilationPupil dilation

-- CyclopentolateCyclopentolate-- PhenylephrinePhenylephrine

nn Relieve painRelieve painnn Avoid post synAvoid post synnn Break post synBreak post synnn Reduce risk pupil blockReduce risk pupil block

nn Topical SteroidsTopical Steroids-- Pain reliefPain relief-- Inhibit migration of neutrophilsInhibit migration of neutrophils-- inhibit macrophage accessinhibit macrophage access-- decrease number of B & T lymphocytesdecrease number of B & T lymphocytes-- reduce histamine releasereduce histamine release-- reduce fibroblast proliferation & reduce fibroblast proliferation & collagen depositioncollagen deposition-- inhibit inflammatory activityinhibit inflammatory activity-- inhibit tissue scarring & regeneratoininhibit tissue scarring & regeneratoin

Steroids Derivatives Steroids Derivatives

nn Alcohol, acetate and phosphate baseAlcohol, acetate and phosphate base

nn Needs to be biphasic (to penetrate intact Needs to be biphasic (to penetrate intact hydrophobic and hydrophylic corneal hydrophobic and hydrophylic corneal layers)layers)

nn Alcohol & acetate base Alcohol & acetate base –– better penetration better penetration of the intact corneaof the intact cornea

Available Topical steroidsAvailable Topical steroids

nn Betamethasone sodium phosphate 0.1% Betamethasone sodium phosphate 0.1% –– Betnesol (Celltech)Betnesol (Celltech)nn Dexamethasone Alcohol 0.1% Dexamethasone Alcohol 0.1% -- Maxidex (Alcon)Maxidex (Alcon)nn Dexamethasone sodium phosphate 0.1% Dexamethasone sodium phosphate 0.1% -- Minims (Chauvin)Minims (Chauvin)nn Fluorametholone alcohol 0.1% Fluorametholone alcohol 0.1% -- FML (Allergan)FML (Allergan)nn Hydrocortisone acetate 0.5% Hydrocortisone acetate 0.5% -- non proprietrynon proprietrynn Prednisolone acetate 0.1% Prednisolone acetate 0.1% -- Pred Forte (Allergan)Pred Forte (Allergan)nn Prednisolone sodium phosphate 0.5% Prednisolone sodium phosphate 0.5% -- Predsol (Celltech)Predsol (Celltech)nn Rimexolone ? Acetate 1% Rimexolone ? Acetate 1% -- Vexol (Alcon)Vexol (Alcon)

Risk Effects Risk Effects -- Topical SteroidsTopical Steroids

nn Cataract formationCataract formationnn OHT OHT –– Glaucoma (steroid responder Glaucoma (steroid responder –– 70% of 170% of 1stst

degree F/H of glaucoma sufferers)degree F/H of glaucoma sufferers)nn Retardation of corneal healingRetardation of corneal healingnn Keratitis + aggravate HSKKeratitis + aggravate HSKnn Corneal thinningCorneal thinningnn PtosisPtosisnn Infection Infection –– fungalfungalnn Uveitis!Uveitis!

Px KM Px KM –– 45 year female45 year female

nn Pain / Red RE / Agony!Pain / Red RE / Agony!nn Arrived 10 hour plane journey AsiaArrived 10 hour plane journey Asiann Tender to touch Tender to touch --nn Nausea / blurred / needs to close eyeNausea / blurred / needs to close eyenn Gradual increase in pain past 10 hoursGradual increase in pain past 10 hoursnn Mild similar events in the recent pastMild similar events in the recent pastnn ? Infection? Infectionnn Good General HealthGood General Health

Clinical PresentationClinical Presentationnn VA poor 6/10VA poor 6/10nn SL gross bulbar rednessSL gross bulbar rednessnn Significant corneal oedemaSignificant corneal oedemann Pupil partially dilated & fixedPupil partially dilated & fixednn IOP R 48mmHg L 18Hg (Goldman)IOP R 48mmHg L 18Hg (Goldman)nn Narrow angle Narrow angle –– Shafer grade 0 Shafer grade 0

Angle Closure Glaucoma Angle Closure Glaucoma = Ocular Emergency= Ocular Emergency

First Aid First Aid –– PilocarpinePilocarpine

Same Day Same Day -- Rapid ReferralRapid Referral

Systemic Systemic –– oral & intravenous oral & intravenous DiamoxDiamox

YAG laser PI / ? TrabeculectomyYAG laser PI / ? Trabeculectomy

Beta Blockers / Steroids / Beta Blockers / Steroids / Hyperosmotic agentsHyperosmotic agents

FLASHES & FLOATERSFLASHES & FLOATERS

Examine the patient on the slit Examine the patient on the slit lamplamp

Look at the anterior vitreousLook at the anterior vitreous

uu Dilate the pupilDilate the pupiluu Reduce Reduce ¼¼ width, width,

slit height<pupil, slit height<pupil, use maximum use maximum brightnessbrightness

uu Stir the vitreous: Stir the vitreous: ask the patient to ask the patient to look up, down and look up, down and straight aheadstraight ahead

Look for Vitreous HaemorrhageLook for Vitreous Haemorrhage

nn Numerous opacitiesNumerous opacitiesnn Can happen without Can happen without

retinal tearsretinal tearsnn Compare with other Compare with other

eyeeye

Posterior Vitreous DetachmentPosterior Vitreous Detachment

uu Detached Detached posterior hyaloid posterior hyaloid face behind lens, face behind lens, rippled mobile rippled mobile undulating net undulating net curtaincurtain

‘‘Tobacco dustTobacco dust’’ or Shafer signor Shafer sign

nn pigment clumps, pigment clumps, usually larger, darker usually larger, darker and more irregular and more irregular

nn Can be caused by Can be caused by ocular surgeryocular surgery

Acute posterior vitreous detachment: the Acute posterior vitreous detachment: the predictive value of vitreous pigment and predictive value of vitreous pigment and symptomatologysymptomatology

nn ‘‘presence of pigment in the vitreous gel to be a presence of pigment in the vitreous gel to be a reliable indicator of the presence of a retinal break reliable indicator of the presence of a retinal break in association with an acute PVD occurring in in association with an acute PVD occurring in 23/25 (92%) patients23/25 (92%) patients’’

nn V. Tanner, D. Harle, J. Tan, B. Foote, T. Williamson, and A. ChiV. Tanner, D. Harle, J. Tan, B. Foote, T. Williamson, and A. Chignellgnell Br J Ophthalmol. Br J Ophthalmol. 2000 November; 2000 November; 84(11): 126484(11): 1264––1268. 1268.

Look at Posterior vitreousLook at Posterior vitreous

nn Weiss ringWeiss ring

Look at Posterior PoleLook at Posterior Pole

nn Preretinal Preretinal haemorrhagehaemorrhage

Look at Peripheral RetinaLook at Peripheral Retina

uu Retinal tearsRetinal tearsFF 10% of PVD10% of PVDFF UU--shaped or shaped or

horseshoehorseshoeFF red red

discontinuitiesdiscontinuitiesFF Upper retina Upper retina

75%75%

Look at Peripheral RetinaLook at Peripheral Retina

uu Volk or 3 mirrorVolk or 3 mirroruu Retinal hole or lattice Retinal hole or lattice

degenerationdegeneration

Look at Peripheral RetinaLook at Peripheral Retinauu Retinal Retinal

detachmentdetachmentFF Convex Convex

configuration, configuration, corrugated corrugated appearance, appearance, undulatesundulates

Urgent Referral if Urgent Referral if symptomatic PVD symptomatic PVD with any of the following:with any of the following:

uu ‘‘Tobacco dustTobacco dust’’

uu Vitreous haemorrhageVitreous haemorrhage

uu Retinal tear Retinal tear

uu Retinal hole or lattice degenerationRetinal hole or lattice degeneration

uu Retinal detachmentRetinal detachment

ItIt’’s All About Decision Makings All About Decision Making

nn Accept responsibilityAccept responsibilitynn Work within your scope of practice : Do no harmWork within your scope of practice : Do no harmnn Develop GOS ? Grampian?Develop GOS ? Grampian?nn Develop your skill setDevelop your skill setnn Make GOS workMake GOS worknn Demonstrate all optometric competenciesDemonstrate all optometric competenciesnn Shift the balance of care!Shift the balance of care!nn Develop Level 2 / Independent PrescribingDevelop Level 2 / Independent Prescribing

Conclusion Conclusion –– Can we do More?Can we do More?

nn Professional AspirationProfessional Aspirationnn Fully Utilise Skill SetFully Utilise Skill Setnn Practice Development Practice Development –– Niche Opportunity?Niche Opportunity?

-- additional revenueadditional revenuenn Patient LoyaltyPatient Loyaltynn Practice DiversityPractice Diversity

-- Can we see beyond specs?Can we see beyond specs?nn Public BenefitPublic Benefit

Thanks for your kind attention!Thanks for your kind attention!