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4 Ophthalmology/ ENT/ ObGyn/Urology/ GUM
PAC 7/2005
4.1 Opthalmology
4.1.1 Eye Examination
Thoroughly examine the eyes:
• Test the visual acuity for each eye i.e. x/y where x=metres from the Snellen chart (usually 6), and y=the lowest line that can be read from that distance. If the patient correctly identifies some but not all of the letters on the line, the convention is to record the acuity of the last completely correct line plus the number of letters they got right on the line below.
E.g. 6/6 +4 if they got 4 letters correct on the line below the one marked ‘6’.
If vision is worse than 6/60, move the chart closer to the patient eg 4m, 2m. If that is unsuccessful, record whether the patient can only count finger or has light perception only.
FAILURE TO TEST VISUAL ACUITY IS INDEFENSIBLE
• Look at both eyes. Is there a difference in appearance in normal light? Is one eye or both eyes red (conjunctival injection)? Check movements of the eyes; are they full or does diplopia occur?
• Examine the pupils. Note pupillary responses to light.
• Look at the lids, under the lids, at the cornea, pupil and iris. Examine the sclera. Record the presence of the red reflex.
• Try and see if anything is in the anterior chamber (between iris and cornea)
• Examine the retina with an ophthalmoscope.
4.1.2 Eye Injury
• Corneal abrasion.
The commonest injury. This is usually caused by a fingernail or a leaf or twig in the garden. The patient complains of progressive pain and difficulty in opening the eye. The instillation of 1% amethocaine drops are often necessary just to get the patient to open their eye long enough to assess it and check acuity. Fluorescein drops or impregnated paper strips should be administered to assess the corneal damage.
The ‘cobalt blue’ light on the slit lamp or ophthalmoscope causes injured area to glow a yellow/green. Corneal abrasions usually cause linear or parallel linear uptakes. Acuity is often preserved unless the abrasion lies over the middle of the pupil.
Rx
Chloramphenicol eye ointment TDS for 3 days (more as a lubricant than an antimicrobial)
NSAID orally work well for these patients.
Consider tetanus booster for patients at risk.
If in severe pain dilate the pupil to reduce ciliary spasm
There is no need to patch eyes following local anaesthetic administration.
Do not give patients local anaesthetic drops to take home. They delay corneal healing
The patient should be advised to return if the symptoms are worsening or are still as bad 48 hours from discharge.
• Foreign Body (FB), usually located under the upper lid, or stuck on the cornea.
Anaesthetize the conjunctiva using 1% amethocaine drops, and try to brush away the FB with a cotton bud. If that fails you will need to use the proximal end of a dental needle and a steady hand! Ask for help from a senior or middle grade doctor if this is necessary. Never use any other type of needle. Use the slit lamp for the removal. Give chloramphenicol ointment as for corneal abrasion above.
If a rust ring remains behind after the FB is removed (often seen with metallic FBs), make an appointment at the next eye clinic.
• Arc Eye is an ultra-violet burn to the cornea seen after arc welding (or sun bed use) without eye protection. Both eyes are usually involved resulting in severe pain and watering. Amethocaine is usually required to allow any form of examination. Generalised uptake is seen with Fluorescein. Prescribe oral analgesia. Eye patching the worst affected eye may be helpful.
• Beware of penetrating injuries to the eye. The classic scenario for these involves metal hitting metal and tiny shards flying off at high speed. In these cases no FB can be found on the cornea, but one may be lodged within the globe. Check for uptake with Fluorescein. If there is uptake and no FB is seen and you suspect a high energy injury, X-ray the eyes in the up and down positions. The presence of a penetrating injury clearly requires Ophthalmology referral, analgesia and antibiotics as advised by the receiving team.
• Traumatic Hyphaema (blood in the anterior chamber) may or may not be associated with a penetrating eye injury. Refer all patients to the ophthalmologist acutely.
4.1.3 The Red Eye
Patients commonly present with a red eye with no history of trauma
The clinical features of concern are:
• Pain in the eye (other than just a FB sensation)
• Decrease in visual acuity
• Abnormal pupil reactions
• Corneal abnormalities
The common causes of the red eye are:
a) Conjunctivitis
• This inflammation affecting the conjunctiva and is usually viral (adenovirus) but may be bacterial or due to a foreign body. It may be difficult to distinguish between Iritis and conjunctivitis.
• Classically bacterial infection causes a sticky muco-purulent discharge whilst viral infection causes copious watery discharge and there may be pre-auricular lymphadenopathy.
• Always document the visual acuity.
• Treat with Chloramphenicol Ointment, (although many are viral).
• Refer back to the GP (should be improved in 4/7)
• Give advice regarding cross infection and the use of towels/pillows etc.
b) Ulcerative Keratitis
• Corneal ulceration causes pain with photophobia. The diagnosis is made under fluoroscein staining under slit lamp. Hypopyon implies bacterial infection and is serious.
• Vesicles in the ophthalmic division of the trigeminal nerve indicate herpetic infection. A dendritic branching corneal ulcer is suggestive of herpes simplex infection.
• NEVER USE STEROID EYE DROPS. It is for this reason that you will not find steroid eye drops in the A&E department. Their administration will lead to a drastic deterioration in the condition.
• All corneal ulcers should be referred to the ophthalmologists as corneal scarring is a real danger
c) Orbital Cellulitis
• Cardinal signs are fever, erythema, swelling and proptosis
• Can lead to destruction of the eye and retrobulbar tissues as well as meningitis
• Refer immediately to the ophthalmologists
d) Acute Iritis
• This is a relapsing condition associated with sarcoid, ankylosing spondylitis ulcerative colitis, Behcets, AIDS. Symptoms include acute onset of pain, photophobia floaters, and blurred vision. VA may be decreased. The inflammation is mostly circum-cornea and there may be a small pupil. Pain increase as the eyes converges and accommodate (Talbot’s test) and pain in the affected eye on consensual light reflex testing
• The slit lamp examination may show synaechiae, a hypopyon +/- precipitates in the anterior chamber.
• Refer to the ophthalmologists acutely.
e) Acute Angle Closure Glaucoma
• Increased risk in Long-sighted individuals with a shallow anterior chamber. Sudden blocked absorption of the aqueous humour through the canal of Schlemm may be precipitated by anticholinergic drugs or pupil dilatation.
• There may be a prodrome of headaches blurring and haloes especially in the evenings.
• Acute blockage causes severe pain, nausea and vomiting, a decrease in visual acuity, a hazy cornea and a fixed semi dilated oval pupil.
• Refer acutely to the ophthalmologists
• Dilate the pupil
• Give analgesia (IV morphine and antiemetic)
• Give IV Acetazolamide on Ophthalmic advice
Other Eye Conditions
Subconjunctival Haemorrhage
Results from bleeding from the small vessels under the conjunctiva. Usually results in a solid ‘block’ of bright red blood over an area of the ‘white’ of the eye ….and an anxious patient. Commonly follows coughing or vomiting but can be spontaneous. In the absence of any other signs of illness it is a benign condition. The link with hypertension is weak, but worth checking if only to reassure.
Advise the patient that it will fade but this will take a several weeks and it will go an entertaining range of colours in the process
Chalazion
Blockage of a Meibomian gland of the eyelid results in a small discrete swelling of the eyelid set back form the lid margin. Give Chloramphenicol and oral antibiotics if it looks infected. If there is an abscess or if vision is affected refer to Ophthalmology (for excision).
Dacrocystitis
Infection of the Lacrimal sac, resulting in a swelling of the nasal margin of the lower eyelid. Can become markedly swollen. Pus may be expressed from the eyelid on gentle pressure. If early treat with oral antibiotics and eye OPD, if advanced refer to ophthalmology.
Stye
Infection of a hair root. Treat with topical antibiotics and warm compresses.