Page 94 - IDF Journal 2023

IDF News – Spring 2023
Eye Conditions
Red Flags for GP’s and When to Refer
Mr Romil Patel
This article is written to be a practical guide, relevant for those in a primary care setting with no access to slit lamp findings and an assumption that no retinal view is possible.
Acute angle closure glaucoma (AACG)
The AACG presentation is usually a red, painful eye with an associated loss in vision, usually unilateral.
Risk factors include age, as the lens becomes bulkier and can close off the drainage angles. Long-sighted patients (plus on their prescription) are more
at risk as the drainage angles may be susceptible to closing off, and conversely, less common in myopic patients (minus on their prescription). If they have had previous cataract surgery in the eye in question, it makes the diagnosis of AACG extremely unlikely.
Remember, AACG can present in atypical ways such as nausea, vomiting and even abdominal pain. Always check the eyes do not appear red or inflamed.
A simple means of getting an approximate Intra ocular pressure (IOP)
is by feeling the globe with the eye
lids shut. Using both index fingers
(one on each eye), palpate each globe simultaneously to allow a comparison. The globe should feel like a soft squash ball. If it feels like a hard golf ball, it can be a sign of raised IOP.
Management is an immediate referral to the on-call hospital eye service (HES).
Posterior synechiae
Uveitis
This is an inflammation of any particular part of the eye involving uveal tissue. Patients who have suffered from it once are always at risk of developing it again. They may be under the care of an ophthalmology and/or rheumatology service as autoimmune systemic associations are plentiful (e.g. HLAB27 positivity).
Patients present with a history of a non- resolving red, painful and photophobic eye. It is usually unilateral but can be bilateral. Chronic sufferers are usually well aware of their condition and know when they are having a recurrence.
It is impossible to see the important sign of cells in the anterior chamber without a slit lamp. The presence of posterior synechiae (adhesions between the iris and the lens capsule) may be visible and is indicative of past or present inflammation.
Management includes intensive topical steroids commenced by the HES. Red, painful eyes with a loss in vision need
a same day/next day review. Episodes
of recurrence have a slightly less acute need for review, and a discussion with the local team would help guide immediate management.
Metallic corneal foreign body
Trauma
Consider the mechanism of the injury. High velocity small projectiles (from angle grinding/drilling) can penetrate the eye. Eye protection helps but does not exclude a serious injury. If you suspect
a penetrating eye injury, you need a same day review via the on-call team. Gardening injuries such as thorns as well as scratches from pets can penetrate the eye, so have a low threshold for HES referral.
Small foreign bodies can lodge themselves into the cornea and be visible to the naked eye. They need an ophthalmic review and removal under topical anaesthesia with a slit lamp. You can cover with g.chloramphenicol QDS until a next day review.
Scratches from children and other mild trauma are common place and can be managed with g.chloramphenicol QDS for 5 days and eye lubrication. Caution is needed if patients have had previous eye surgery e.g., a corneal graft. Most injuries are self-limiting, so if they continue to be painful/problematic after 5 days, then
a HES review is indicated. Sometimes there can be a mild degree of uveitis post trauma which requires topical steroids.
Evidence of obvious globe rupture requires same day review and a clear acrylic shield over the eye (do not attempt further examination of the eye).
Chemical injuries can be nasty, and the most effective intervention you can do
in the primary care setting is to put in some topical anaesthesia and irrigate the eye with 1L normal saline and then hand over to the HES. Alkali burns are more damaging to the eye than acid ones.
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All images are courtesy of Mr Scott Hau, Principal optometrist & research optometrist at Moorfields Eye Hospital NHS Foundation Trust.