Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yeah. Okay. So let me know whenever you're ready for me to go. Get going. Hi, everyone. Thank you for joining us today. Um, on today's tutorial on acute presentation and ophthalmology. Um, so today we're joined by Dr Robbie Choudhry, who is an ophthalmology training doctor who's very experienced with working in acute department in oncology, like, um, casualty. And so, and he'll go into more about his background when I pass the queen over to him. So I hope you will have a very, very good tutorial over to be alright. Brilliant. So good evening. My name is Robbie Choudhry. I'm an ophthalmology registrar currently working inborn with in the south of England. Um, I apologize for the video quality at the moment. I'm working from quite an old laptop rather than my normal computer, but I hope that all of you can see and hear me. Good enough. Um, if you've got any questions at all throughout this, please feel free to put them through in the chat box. And I'll do my best to answer this throughout. Um, no, I can't see who is actually attending this at the moment, but, uh, just please make yourself known in the chat box. And if you have any questions, feel free to to chip in. I wanted to, ideally, to make this as interactive as possible. Um, but again, if I can't see you, just please put your questions on the chat box, and I'll do my best to answer so well, we've actually got quite a lot of people attending. I'm glad to see him. Glad to hear that. And I hope some of you have an interest in ophthalmology. Um, regardless of whether you do or not, I'm sure this will be a useful presentation for you. So I'm just going to try and share my screen now, um, there with me a moment. Okay. Let me enlarge this. So can someone just let me know whether you can see my see my screen or not? Just drop it in the chat. If someone can can see the presentation on the screen. Okay. Brilliant. Fine. So my presentation is about acute presentation in ophthalmology, and I'm gearing this presentation towards General Doctor's Foundation Year one foundation year to, um, to be the sort of things that you might you might come up with in your clinical practice, so you might often get that presentation. Do you see, for example, just on the ward saying, Oh, Doctor, my eyes a bit uncomfortable? Or you might see a patient who's got red eye. And you think, Oh, is it just the conjunctivitis or is it something more serious? Um, or you might be doctors working in casualty, and you often have some acute presentations with very sore eyes or traumatic I injuries. Um, so this is going to be a bit of a whistle stop tour. There's a lot to cover. Um, so let's jump right into it then. So I've got a couple of key conditions which we're going to be covering today. We're going to start off with a bit of a recap of the anatomy of the eye and things that you need to examine the eye. So, for example, if you wanted to refer a patient's ophthalmology, what kind of information would we be looking for? Um, from from yourselves, in order to try and figure out exactly what's going on? So starting off with the basic eye examination, if you think back to your time in medical school, you might have touched on the eye exam when you were doing your neurological exam. Now I remember the neuro part of the examination was always quite tricky, and you have to sort of wrote, learn each step. And I also remember being back at medical school that you'd be taught how to use the indirect ophthalmoscope a little ophthalmoscope you hold up to your eye. Um, yes, it's It's something which we all sort of struggle to learn for exams. But in reality, it's not something that we use regularly on a day to day basis, and you might find it interesting that actually, is ophthalmologists. We hardly ever use that indirect ophthalmoscope. It's actually it's a tool which has used, but it's got quite a limited use, so it's very good at looking at the optic nerve itself. But actually, in the absence of using a direct ophthalmoscope, there's quite a lot that you can tell just by your your crude exams just by examining the patient and looking at the patient with your with your with your eyes and your basic examination skills. So first things first, like prior to any examination, you need to take a good history and consider the patient holistically. So first off, what is the presenting complaint? A patient might come to you saying that they've got they've got pain in their eyes, for example. So think of think of your usual Socrates or your your way of assessing a patient with pain. Where exactly is the pain? Um, it might sound like a trivial question, but is the pain just on the surface of the eye? So it's just on the outer part of the eye, in which case it can be said due to dry, I could be due to a foreign body. Um, it could be due to allergic eye disease. There's a lot of different possibilities, depending on where the pain is. If it's not at the front of the eye, Perhaps it's, um, perhaps it's around the eye itself. So when you look at the patient, is there swelling of the skin around the I? Could it be something like a preseptal cellulitis, the skin infection affecting the skin around the eyeball itself? Could it be pain that's in the in the brow itself? Does it localized anywhere to certain parts around the eye? For example, if it's pain that's affecting the eyebrows or the frontal Sinuses? Maxillary Sinuses. Um, could it be a sinusitis? That's actually something which we do see an eye casualty a lot. Patient is referred with having pain around the eye, and it's actually a sinusitis. Um, is it pain affecting anywhere else of the of the head? Is it affecting the temples? Could it be related to giant cell arthritis? Is it affecting a certain half of the head? Could it be a migraine, for example? That's also something that presents I casualty with visual loss. So, as you see, it's very important that we take a good history to try and work out exactly what the pathology is. Next, we go on to the history of the presenting complaint. So how long has the symptoms been going on? For if it's a if it's, say, vision loss? If it's an acute vision loss, then you're thinking of perhaps more serious pathology. Is it a vascular pathology? Is it a blockage of the artery in the back of the eye? Is it a T I A. Is it a small clot going into vessels in the back of the eye, causing acute vision loss? There's all things like this to concern to to consider in diabetics, for example, they can have acute vision loss if they've had small bleeds into the eye. That's something which we see very often and casualty. Um, so it's important to consider the present the history of the presenting complaint. If it's a gradual decrease in vision over time, say, over months, two years, it could. It could well be something like a cataract, which is developing. So this time course is something which is very useful for us when, when taking our basic history, then, like you would do your past medical history and a general medical examination, we move onto doing the past ocular history. So for us in ophthalmology, it's actually quite useful to know what procedures the patient has had on the eye before, as it helps us to rule out certain pathologies. So, for example, if they've had cataract surgery done, um, cataract surgery is quite an interesting one, because it's it actually means that they can't necessarily have an acute angle closure, glaucoma and cataracts surgery. We replace the patient's old and thickened and up a cleanse that's naturally within the eye with the thin artificial plastic lens. So actually, when when you're speaking to ophthalmology over the phone, um, whether the patients had previous cataract surgery or not can be useful in ruling out, say, acute angle closure. Um, has the patient had, uh, previous procedures on the eye in order to reduce the eye pressure? So have they had something called a trabeculectomy? Um, knowing whether the patients had glaucoma and any procedures for that is also quite useful. Um, as, for example, a procedure which is known as a trabeculectomy. So putting a small hole in the eye in order to allow fluid drainage to bring the pressure down is always a persistent source of infection for the patients. So that's something which is useful for us to know and also in trauma cases. For example, if a patient had a lens inserted into the eye, then with trauma, a punch to the eye or an elderly patient that's had a fall that can cause dislocation of that lens as well. Moving onto the past medical history, we almost always want to know whether the patient has hypertension or diabetes, as these quite often cause problems at the back of the eye for example, in a patient presented with acute vision loss. If they're very, very hypertensive, then they can have something which is called a central, central retinal or branch retinal vein occlusion. If the arterial pressure is too high within the eye, that can apply pressure onto the veins, which caused them to hemorrhage. For example, Um, um, we would also be interested in looking to see whether they've had diabetes. There's a lot of presentations. I casualty our diabetes related. So diabetic patients often have very new a lot of new vessels that go into the back of the eye. These vessels are very flimsy and fragile and tend to break very easily. So often a patient might present with sudden vision loss in that eye. And when we come to have a look at the back of the eye with the slit lamp, we find that the whole of the back of the eye is filled with blood. So that's why past medical history is is quite important for us to know about the patient's other medical conditions are the systemic conditions which may manifest in the eye. Other systemic conditions which can affect the eye, includes autoimmune conditions. So do they have rheumatoid arthritis? For example, do they have ankylosing spondylitis? These can all be associated with inflammation in the front of the eye, which is known as you the itis. And that's a very common presentation to casualty as well. I don't want to dwell on this all of this too long, but I hope it drills home the point that, uh, medical history and history taking is is crucial. Um, in order to figure out what's going on with the patient, not just with ophthalmology, but with whatever feel that you're in. Family history is important when looking at patients eyes as, for example, if they've got a family history of glaucoma, then the patient themselves may be developing signs of glaucoma and not be aware of it. Um, there may be other genetic conditions which affect the eye as well, which can run in the family. So, for example, I think just two weeks ago I saw a patient who had a family history of congenital cataracts and interestingly, this this patient, um as well as her, her own Children and grandchildren. They all had cataracts in their eyes from when they were born. and they required surgery for this at an early age or else they weren't able to see. So that's an example of where family history can be relevant. Um, also, social history is quite important as well, because you need to consider the occupation of the patients. What do they do for a living? If if, for example, they work as a lorry driver, then anything is affecting your vision may actually restrict their ability to drive. Maybe they are the sole care, er, for a member of their family. Maybe they need to drive their Children to two and from school. Um, these are important for us to know in ophthalmology, as we might have to dilate the back of their eyes. And if we put dilating drops in, they can often take a couple of hours before they settle. Also, any acute pathology affecting the patient's vision or affecting their visual fields might mean that they're not safe to drive, for example. So that's important to know, too. And last but not least, we move on to their patients medications and their allergies medications not only the systemic medications are they on anti hypertensives. Are they on diabetic Asians, um, but also eyedrops as well. Are they taking drops for the glaucoma? For example, How regularly are they taking their drops? Are they missing? Any can be useful to note and allergies as well. Um, so if the patient has any intolerances, you might not be able to use certain types of antibiotics. If a patient is asthmatic, for example, or Scott COPD, you might not be able to give beta blocker drops in order to bring the pressure down within the eye. If the patient has chronic kidney disease coming back to the medical history, if they come in with acute angle closure and you need to bring the pressure in the eye down with medications, then these medications can be nephrotoxic of cause issues with the kidneys. So again, just I want to really drive home the point that the history is crucial. So when you're examining patients, the tools your needs are as follows. So number one, um, first off, you want to be able to assess the visual acuity, so how do you actually do that? So when when I was taught back at medical school, we used to try really crude measures of measuring a patient the A. We'll be doing things like using our own name, badge and holding it up in front of the patients, asking, Can they see that? And again, that can be quite good for comparing a patient with good vision with one eye to the other. Um, but again, the ideally, we'd like to have patients having a measure of their smell and visual acuity. If you're in casualties, there might be one of these charts around somewhere. If you ask one of your consultants, Uh, most often there is. There is, if you ask around, but it might not be the easiest to find, but what you can do is you can download a smell and chart app on to your mobile phone, and particularly for us in ophthalmology when we're on call. It can be very useful to assess patients visual acuity with that Now. Another thing to bear in mind when you're measuring the patient's visual acuity is that you should do this one eye at a time, so in a pinch you can get the patient to hold their palm up in front of their eye to cover one side and to check with one eye at a time. But actually, um, you may also find something like an occluder, which you can hold in front of the patients as well, which may make things a bit easier for you. And these include, as often have pinholes as well. So pin holes are very useful when testing visual acuity as they give us an idea of what the patient's best corrected vision will be. So if the patient doesn't have their glasses, or if the glasses are not properly correcting them. If you pop a pin hole in front of their eye, it only allows rays of light from a single point to hit the retina. And so it gives us a good good impression of how, how, what their optimal vision is, um, coming back to the other pieces of equipment so occluded and pin holes are handy. Uh, pen. Torture, especially, is very useful in terms of checking the reflexes in the eye. But again, if you don't have that to a hand, then you can always use your mobile phone just with your normal lights to hand shining at one eye at a time, for example, to check the direct and consensual reflexes and swinging between the eyes to check the r a p D um, in in general casualty or in general practice, you might be lucky if you have some flurries in drops. Um, so flu vaccine is a fluorescent die, which you can pop a single drop in to have a look at the front surface of the eye. And if there's any abrasion to the front of the eye or dry eye, or a lot of other pathology is affecting the cornea, the clear layer of the front of the eye. Then this shows this up when you shine a blue light at it. And it's something which we use in ophthalmology on pretty much, you know, a lot of patients that we see on a day to day basis we're using this for cotton buds can be useful for averting the eyelid. So in casualty, if a patient comes in and they've got a suspected foreign body in the eye, and then you need to make have a good look underneath the eyelid in order to make sure there's nothing still stuck up there, um, direct ophthalmoscope can be useful for looking at the nerves at the back of the eye. But realistically, it's It's something we don't really do all that often as general doctors. So it can be quite tricky. But still, if you if you have one, give it a shot. It's difficult to get a good view if you don't dilate the patient size, but there's no harm in trying. And also another very useful tool is a smart phone, Um, not only for checking the patient's visual acuity, but actually for tracking the patient's pathology over time so you can ask the patient to take a picture of there. I, um and then again, if things are getting worse if, say, for example, they've got eyelid swelling or bleeding or bruising around the eye, and they can track that with photos over time and often we have a lot of patients that will do this anyway without without even being told so again, I talk about including and pin holes here, and I wanted to introduce you to a piece of equipment which I got actually as a as a B m. A free gift. So I think when I signed up for for membership, I got this thing, which is called an arc light, and it's almost like it's an all in one tool, which can be used as a both a crude ophthalmoscope but also an auto scope. So I'm not sure if you can see my pointer here, but if you have a look at the third picture in the middle, you can see the otoscope tip, which is used there, and then for the images on the left. You can see that it's gotta button in order to turn the light on and off. If you click it again, it will give you a blue light, which can be used to look at Florida. Seem to see any abrasions or any any scratches at the front of the eye. And in the case on the right, you can see it's got a small paper. It's really fabric, a small swelling chart, which you can use to look at patients. Visual acuity. All right, So, um, has anyone got any questions so far before I move on to different conditions? Any questions at all about basic examination, ideas, concerns, expectations, anything at all? Now is the time to ask. Give it another couple of seconds in case anyone does have any questions. I've got a I've got a question to you, actually. So assuming that you're testing a patient's vision and they can't read the letter on the chart, if they can't read the biggest letter on the chart, what would you What would you do at that point? Did anyone have any ideas? How do we measure vision that's poorer than reading the largest letter on the chart? So while you're thinking about that, um, I'm just going to go through the questions. So question from a cash, what's the most common presentation? That's a very good question. Um, so let me see if I can show you a screen there with me a moment. So I did a quick, quick look at what? Our presentations. We're in our local I units. I casualty so within the last year, these are the top 10 coded top 10 coded diagnoses that we diagnosed patients with. That has come to I casualty. Um, a lot of bear in mind. A lot of these are associated with other conditions, so you might see a patient that comes in with dry eyes. Um, and that's a secondary diagnosis to something else. But actually, that's one of the one of the conditions which we diagnosed the most. In my casualty. That's not usually the presentation, but it's also it's one of the secondary conditions that they have so dry eyes. More than about 1.5 1000 patients were diagnosed within the last year. Corneal abrasion is also very popular. 1.3000. Um, anterior uveitis. We see an awful lot in I casualty. So inflammation of the front of the eye, which requires steroid treatments. We see a lot. Um, Then we get referred A lot of patients who've got flashes and floaters. So patients may have what's called the posterior vitreous detachment, which is where the gel starts to separate in the back of the eye. And as it does, it pulls on the part of the retina, and it can cause the sensation of flashing lights or new floaters. So we see that an awful lot again physical things. So foreign bodies. Corneille sub tassel, which means under the upper eyelid, which again, is why you check underneath the eyelids. Blepharitis another one of those associated conditions. Corneal ulcer. We see. We see a lot as well, which requires antibiotic treatments. So, really, these are the top 10 diagnoses, but there's a lot of other acute acute eye conditions. Acute emergencies which will get into they don't necessarily make up the numbers, but we do see them on a day to day basis. So coming back to the presentation, do you have any other questions? Okay. Yeah. So, uh, well said so if you can't if you can't test the visual acuity by using a chart for more crude assessment, you can do, uh, counting fingers. So if you just hold up your fingers in front of the patients and ask them how many can you see and ask them to count it? Um, that's the next step down. And beyond that, then you can use hand movements. Um, so if you wait a hand in front of them and you include the other, I can. They see the hand moving. And beyond that, it's perception of light. So if you shine a light in front of them, can they even see that light or not? Um so, yes, that's a very good well done. All right. So moving on. So, in terms of equipment, so Yes, you can use the direct ophthalmoscope, but actually an ophthalmology. We hardly ever use it. And we prefer to use the slit lamp instead. Um, part of the reason for that is is we get using a slip beam. We can almost perform a cross section of the different layers of the eye, which you can't do with a direct ophthalmoscope. And also, we get a much larger view of the fungus or a greater greater field of view compared to the director ophthalmoscope. So again, um, although we're talking at medical school in practice, we hardly almost never used the director. Right? So I did want this to be an interactive session on the basic anatomy, but I think this is going to be a bit tricky just over the voice chat. Um, so, going over the anatomy from the various parts of the eye, Uh, if you start at the front of the eye, uh, let's have a look. So D so can you put in what you think that front part of the eye is? Just put it in the tax chart 21. Okay, I think we'll we'll we'll go through this quickly that in that case, So Part D. At the front of the eye is the cornea, so starting at the front of the eye, we go externally, so lids and lashes first. Next, we move on to the cornea, which is the clear window at the front of the eye, which is marked in D, moving behind. That is what's called the anterior chamber. So it's a fluid filled space, and if a patient has, for example, inflammation or infection, you can see that in the front part of the eye. So you might see some puss in that part, which is called Hypo Pee in. Um, if you have a look with the slit lamp, you can see small cells in that part of the eye in Uveitis. If patients had trauma to the eye, then you might actually see a fluid level with blood in the front part of the eye. That's called a high fever, moving behind that you've got the virus, which is the colored part of the eye, um, moving further backwards. We've got the lens, which is marked in E, so it's clear as Children and and as you get older, it can become a pacified with cataracts. Also after trauma, the lens can become a fake. Um, just surrounding that, you've got the zonule, which hold the lens in place of the patient has had very severe trauma. Then that those can be disrupted and the lens can move out of place. A chest. The ciliary body, which is the structure which produces aqueous humor So fluid in the in the front part of the eye. Um, a lot of the drops we give for glaucoma can actually actually affect that part of the eye. Moving behind X is the vitreous cavity patient. They have floaters or bleeding there, Um, moving backwards. A is the retina. I is the optic nerve and optic disc and moving behind that we've got the, uh, b, which is, I think is meant to represent the choroid. And behind that, we've got the sclera, which is the white out a tough part of the eye and behind is J, which is the optical. Oh, yeah, um, again. So moving on to the outer outer part of the I again, I would have liked to have done This is an interactive session, but I think it's a bit tricky with the chat as it is at the moment. So having a look at the outer part of the eye again looking, we always look at the at the outer lids and the lashes. The black bit is the pupil in the center of the eye, so this can be distorted if the patient has uveitis inflammation in the front of the eye. If a patient has trauma, the pupil shape can be quite irregular. We've got this out of line here. So just outside the iris we've got what's called the Limbus, which is where the eye has new stem cells, which grow to form the cornea, the front layer of the eye. We've got the white part over here, which is the conjunctiva for, um, so in conjunctivitis infection, it can become quite inflamed, and it's got the white sclera behind it as well. So it's Claire itis. There may be inflammation of that as well. No, so moving on words. So we have a patient who has a red eye here, so, you know, ocular red eye. This is a very common presentation. Again, we tend we tend not to see it as much in my casualty or If it is, then it's it's seen by the nurses working in the practice or they may be it may present to you to you as a GP, for example. So can anyone take a guess at what a common presentation of Red Eye is? So to give you a bit of history, this patient may say, I've got a bit of gritty sensation in one eye irritation and I've got a bit of discharge as well. My eyes watering quite a lot. Thank you. And yeah, we've got conjunctivitis in the in the chat over here. Yeah, so that's a very, very common presentation in a in a cute in acute setting. So sorry. In a GP setting, you don't see this a lot. So as I mentioned the patient, we have gritty I foreign body sensation. Um the redness typically affects all of the conjunctiva. And that's actually an important point. Because if a patient may have something like an episode arthritis or a scare itis, then it may be focal. It may only be a small part of the conjunctiva that's affected. There's different pathophysiology behind it. So it may be a bacterial conjunctivitis, in which case the patient may have a lot of discharge, which may be new cup or alliance. Then they complain if they're lashes being stuck together, particularly when they wake up in the morning. Um, it may be viral. In which case, it's, uh, it's often just the watery eye. They may have other associated viral symptoms, such as a sore throat. They may have swollen lymph nodes, for example, in the preauricular nodes in the neck as well. Um, and again they may have both pinkness or redness of the eye. But if you pull the eye lid down and have a look in the fornix, the the Conjunctiva, which is there as well, may also be quite inflamed. So that's also a good hint. The other category of conjunctivitis would be allergic, so patients may, um, patients may get this several times throughout the year. They may have hay fever or other allergic or a topic disease, which can be associated with it, and we can treat that with with other other special eye drops. And again, commonly, the patient will complain of blurring of vision with this as well. So as you can see in this image over here, This patient's got quite a lot of mucus, a parent discharge, which is in keeping with a bacterial conjunctivitis. When you see a patient with a bacterial conjunctivitis again coming back to the history, it's important to think about their systemic conditions. So are they, you know, compromised? Do they have? Do they have, for example, HIV, hepatitis? Are they a diabetic patient, in which case infection can progress quite rapidly or they may get recurrent infection? Um, also is the patient sexually active as, for example, they may have gonorrhea or chlamydia, which is affecting, which is affecting the eye as well? Um, in which case you can consider sending off swabs. But again, if you have any concern that this is not getting any better, then by all means give us a call ophthalmology, and we're happy. This information, So treatment for bacterial conjunctivitis would be chloramphenicol drops four times a day, usually for about 7 to 10 days. And in the vast majority of cases, conjunctivitis is a condition which is self limiting. So again, it's not something to be particularly particularly concerned about with viral conjunctivitis. Again, it's a self limiting condition. You can give topical lubricants in order to help soothe the front of the eye. Um, so topical lubricants will get into it shortly, but these will be things such as high low four drops. Um, theological duo any over the counter lubricants, which the patient can use and usually because they're preservative free. There's no upper limits or how often the patient can use them, so you might advise them to use them maybe six times a day, once every two hours. Hourly. There's no upper limit in ophthalmology. We sort of go crazy with the lubricant drops. So just, you know, tell the patient to use it as and when needed. Bear in mind with viral conjunctivitis, symptoms may take several weeks before they fully resolve, but in that time it's important that you advise the patient to remove their contact lenses as you don't want. Um, as you don't want this being a source of infection, and it's crucial that you tell them about maintaining good hand hygiene because if they get it in one eye, then they may inadvertently pass it to the other eye or the other members of their family. So also tell them to to not share towels in their household as well. Again, if anyone has any questions, please put them in the chat. Um, I can't see the the chat on the on the other apps. So if any admissions, um, could copy some questions over to the the chat that's on on on Zoom that would be appreciated. It gritty eyes is a is something which patients may may tell you about. So with this again, look at the history. How long has it been going on for? Is it after an acute trauma? Or patients been doing some work in the garden or working with tools as they may have a foreign body and underneath their eyelids? So again, this is where the cotton buds will come in handy. What you can do is if you grab their grab their lower the lashes of the upper eyelid and hold the end of the cotton. But in the in the fold or in the upper eyelid, you can flip the eyelid up and have a look underneath it. So in this image in the top right, you can see there's a small foreign body, which is just underneath the edge of the eyelid and if there is a concern over a foreign body, then again, probably best to get in touch with with ophthalmology. But what we normally do is we put a bit of numbing drop on the on the I. We use something like a cotton bardo, a very small needle in order to try and flick that foreign body out again. If we still can't remove it, then we could. You know, we can use a small burr or a small tool in order to drill or to remove that from the from the eye. Um, it's very useful in patients presenting with pretty eyes to put Claritin drops in. So again, flu vaccine. As your friends use these colored drops, have a look at the cornea. And if you see lots of very small dots all over, as you do in this lower picture here, that's quite characteristic of dry eyes. And the management of it is lubricants. So well, come on to that in a little bit again. If a patient is complaining of gritty eyes, you might want to look at, how well can they even close their eyes? So in this photograph in the middle, there's a patient trying to close his right eye. And he's got some lung doctor almost so he can't close the I completely. And there's part of the cornea showing. So, for example, in a patient with a bell's palsy, you might get them presenting with DR associated with It or inability to close the eye. And in such a case, you might advise them to keep the I taped shut. So if you keep the I close the eyelid, take the eye shut At nighttime. You can use regular lubricants throughout the daytime and thicker ointment at nighttime, as well as some antibiotic ointment in order to protect the iPhone infection. Lubricants, as I mentioned, includes um, includes high low thoughts theologians duo Hailo nights. And there's various other appointments, such as Byetta past, which you can use to keep the eye moist and prevent dryness from worsening. Blepharitis is also quite a common thing. So in patients that are presenting with dry or irritated eyes, it's not really something that would come to a general casualty. It might just be award patient that's complaining of this patient coming to you as a GP. Um, they might complain of gritty eyelids redness of the eye that they're rubbing their iron awful lot. But when we have a look at it with the slit lamp, it looks like crusting of the outer lashes, slight redness of the eyelid margins. Or if we have a look at the inner the margins of the lid, then we can see some clogging of these meibomian glands. That's quite characteristic of what's called blepharitis. The information of the eyelid margin. What we advise patients is that they clean their eyelids with a flannel, which is soak it in warm water. They do this, uh, at least twice, maybe more, in the daytime and gently rub or massage the eyelids, uh, in order to help express and fluid from these clogged up glands and in order to wipe away any any dirt or debris at the Irish eyelid margin. If this is very severe, then we can give chloramphenicol ointment twice a day to live margins for a month. And if it's posterior left right, it's affecting the liver margins. Then we may also give them some doxycycline tablets to treat that as well, but again, it's more, more, more often than not, a chronic condition and you just need to advise the patient that if things do get any worse, so if they're spreading spreading redness over the eyelids, if they develop fevers at all, then you could be concerned with something such as a preseptal cellulitis. So again, if things do get any worse spreading of redness over the eye and over the face or fevers, then obviously safety, let them and get them. Eyelid lumps of are things which can commonly present in in general practice. So along with with uh, with the discomfort of having a lump in the front of the the eyelids, the patient may complain of some blurring of vision and some watering of the I. Sometimes the lump can be so large that it generally presses on the front of the eye itself, which distorts the front of the cornea, which causes blurring of vision. The key question. If you see a patient with an IV drug, is that tender or non tender? Um, so if the lump is nontender, then more often than not, it's actually what's called a collision. Uh, which again is a lump, which forms within the within the eyelids. Um, if it's a tender lump, then it's more likely to be what's called a stye, which is a small cyst, which is at the base of the eyelashes, will come on to that in a little bit again, with any redness or lumps around the eye, you need to ask the patient, Is this redness spreading? Is it worsening? And do they have any fevers with it, as that can be concerning for cellulitis, um, again, preseptal cellulitis, orbital cellulitis can eventually going to affect the brain. It can be very serious, so we always need to be aware of that as soon as you as soon as you think. That's a possibility for collision. However non you know, non painful lump at the the eyelids. The management is warm, compresses and again, safety. Let them if things get worse. Um, as I mentioned before, that lumps at the edge of the eyelids, particularly the base of the lashes, which are painful, is more likely to be what's called a stye. And in this case, what we would usually do is remove the remove the affected eyelash to provide a bit of a drainage channel, and we'd apply chloramphenicol ointment three times a day for 1 to 2 weeks to the eyelid margins. You can also advise the patient to use warm compresses. So again, the warm flannel and hot water against the eyelids, which can help to help to unclog some of the glands at the edge of the eyelid and also help help this to drain a bit better. If there is concern of spreading cellulitis over the eyelids, then you can give them the oral. Caremark's a cloud, um, and again please get in touch with ophthalmology if there's any concern over preseptal sector. So if a patient comes in, patient may present to a general casualty, for example, say that they scratched the I. They've got something in there. I they rubbed it, or a piece of dirt is flowing up into the eye. Um, again, I always try and put some fluoride drops in, if you can. They I think they do have them. In most General A Andy departments, if you ask around when you put that in and have a look under the blue, I you may see some scratches on the front of the eye, Um, patient. Because of this, because of the cornea being so sensitive. They may have a lot of pain and watering of the eye photophobia and tearing of the eye as well. So if you can try and put some numbing drops into the I tha in order to make it easier to examine, as I mentioned before, avert the lids. So in this patient's I, you can see a lot of linear scratches, and more often than not, that's actually due to a foreign body underneath the eyelids. So when the eyelid comes down, um, it scratches on the front of the eye, causing this causing an abrasion. You always want to take a history looking at looking at what the mechanism of the injury was. So was there a trauma involved? Was there a quite a severe injury? Had the patient fallen down? Is there a risk of penetration of the eye itself? So is the pupil irregular? Um, that may be a warning sign of a penetrating injury, but if you're not, if you're happy with it, being something affecting just the front part of the eye, the pupils regular reactive, you can give a drop of chloramphenicol and then give chloramphenicol four times a day over the next week or so. But again, as I would say, if there is any concern over any of these eye related issues, please give ophthalmology a call, and we're very happy to help. Just as long as you've got the basics of the history and basics of a rough examination, then that will help us a lot in in order to come to a diagnosis. So hopefully you won't see something like this. Um, in this case, the patient has got a penetrating injury to the eye. You can see this diagonal line going across the cornea, where the cornea has a penetrating injury. There's a break in the cornea, and you can see that the virus in this case is irregular. Often that's because the the virus, the colored part of the eye, wants to escape through the wounds. So again, always look at the the pupil and the Irish and see whether that's irregular as that can be. A warning sign for penetrating injury If it's a patient who is coming with a with a trauma, or you suspect there could be a fracture of the bones around the eye, um, it's always good to have a look at the patient's eye movements. So if you hold your finger up in front of the patients, um, and for the H pattern so like you would do for a neurological exam, move the finger all the way to one side, up, down, back, across, up and down. And look for the patients I movements. If there is any restriction of eye movement and it's a trauma case, um, then you might want to consider doing a CT scan of the orbit. Um, sometimes if there's a trauma to the orbits or as an orbital fracture that can affect how the the eye moves. Um, and if there is concern over orbital fracture again, give ophthalmology a call, give maxillofacial call. Um, and we take it from there. Preseptal cellulitis. So it's a condition, which is common, particularly in Children, because they have other other Sinus infections or respiratory tract infections or immune compromised patients. So diabetics the elderly patients with HIV, other sources of immunocompromised Um, it's an infection of the of the of the skin that's basically around the eye, Um, and as you can see, it might manifest as a red eyelid in a patient. Um, so again. I always check. The patient's pupil response is as if the if it progresses to affect the back of the eye. And it's an abscess or infection affecting the rest of the orbit and orbital cellulitis, then that can affect the pupil response as well. Check out the patient is physically. You need to check their physical obs their temperature. Are they systemically unwell? Do they need IV antibiotic treatment? However, if they're systemically well, it's just an infection affecting the outer eyelids or it seems quite mild. Then you might be able to get away with giving them all tamoxifen regularly and again discussed with ophthalmology. However, if they're very systemically unwell, then you'd want to consider admitting them for IV antibiotics and again discussing with ophthalmology in order to rule out an orbital cellulitis. So if there is any concern of orbital cellulitis whatsoever, please discuss with ophthalmology um, or E n t. If they have any other respiratory signs, any any signs of, uh, sinusitis, for example, manage them according to your sepsis protocol. Give urgent IV antibiotics. According to the hospital policy, Um, consider doing a CT scan of the orbit, Sinuses and brain, so for example, if they have any optic nerve involvement. If the pupil is not reacting well, um, if the eye movements are affected, or if if ophthalmology is advised to consider doing a CT scan again concerning features of any form of swelling around the I include proptosis of the eye. Any restriction of the eye movements are are a P. D. Um, The bottom line is, if your concerns then give us a call corneal ulcers. So this is something which presents to I casualty a lot again with all all pathology that's affecting the front of the eye. Fluorazide is your friend. So if you pop a drop of fluid scene and have a look under blue light and then you can see a large, you see a large ulcer again. Consider if the patient can compromise. Why have they got the ulcer in the first place? Is it because they're wearing contact lenses, in which case you'll advise them to take out the contact lens? You may actually send off the contact lens for culture, which we do an ophthalmology quite a lot, Um, again, Corneal ulcers can progress quite rapidly and cause a melt in the front of the eye. So it's It's something which is quite serious in terms of the patient's long term visual outcome. So always discuss these cases with ophthalmology. Tell them to remove any contact lenses. Um, give antibiotics as advised by ophthalmology. Now, with flu vaccine, flu vaccine can help you to distinguish exactly what the cause of the answer is, and something which we see often in my casualty is a dendritic ulcer. Um, does anyone know what what the cause of this is? If you have any ideas, put it in the chat. So a dendritic ulcer is often quite, it's quite characteristic. And when I say dendritic, it looks like then right? Almost looks like a tree branching out over the front surface of the eye. Um, yeah, so someone's put in herpes simplex virus. Yeah, so herpes simplex can affect the front of the eye, and patients often present quite quite frequently to casualty with this, so they had it once in the past. They may get several repeat episodes of this, um, in which case you want to start them on topical anti virals so you can use what's called ganciclovir appointment, which is used quite frequently. It can be used about five times a day and again, you want to get them seen by ophthalmology as well. Um, so in ophthalmology, we'll review different parts of the eye. So corneal ulcers may be associated with inflammation within the front part of the eye, and they may also affect the back of the eye. And it can be quite serious. So again, all of these patients I would advise you to discuss with ophthalmology, and then we'll look into the casualties, check them out cheap. You might see a patient who presents like this to, uh, generally D. So this is what how a patient might manifest with with shingles, So herpes zoster ophthalmicus. So remember, with shingles, it affects just It's just 11 dermatome on one side of the body. So in this patient you can see how it's affected all of her, all of her forehead, and it's affecting the nose as well. And it's affecting the eye, too. So we do see these quite often in elderly patients or if you're compromised patients, Um, but it's it's reactivation of the varicella zoster virus for management. We treat them with your acyclovir 800 mg, five times daily for 7 to 10 days. We also cover them to prevent any bacterial infection of the eye as well. So we give them the chloramphenicol ointment four times a day. Um, you want to see as well How well can they close the eyelids? Um, again, that can, if they can close the eyelid very well and the that can cause damage to the front part of the eye. But again give ophthalmology a call. We're very happy to review these patients. And we would also consider admitting these patients if they're very elderly or unwell again because of the because it affects the nerves. It can cause quite a lot of neuropathic pain. So you want to consider regular analgesics on the patients. And also, I think you can use, uh, medications to help with neuropathic pain such as amitriptyline. Got a person, for example. So another I emergency, which can come in particularly older patients. Presenting with loss of vision is giant cell arthritis, and this is one which you never want to miss. So patient may present with a localized headache or temporal or scalp tenderness on one side, and they may have an associated sudden decrease in vision on that side as well. So usually patients got a headache, sudden decrease in vision as well as other systemic features such as scalp tenderness, jaw claudication. That's the key question to ask if they've had weight loss night sweating, other myalgias. So think of Polymyalgia rheumatica. Then again, please, please consider Giants arthritis you in order to screen them properly. You want to take blood, including CRP and es are as we use that as part of our screening criteria. So what I've got on the right over here is what's called the GC. A probability score. So both rheumatology and ophthalmology can use this to assess the likelihood of it being a giant cell arthritis. And it looks at features such as the Age of the patient again. These are almost always an older patient. So if you're saying there's a patient in their thirties that's presented with this, then think again. It's most likely to be something else. Um, look at the duration of the onset of symptoms is the CRP race. That's the key feature, and again you can. You can look at the GC Probability sports, which would help us in order to assess the likelihood of this for the patient. If if it is, and if we consider it, then you want to start them on urgent steroids, it's potentially site threatening. The vasculitis can affect the optic nerve at the back of the eye, and I have seen patients that have lost their permanently lost their vision as a result of this. So you start them on all prednisolone 1 mg per kilo, or you could start roughly, maybe 16 60 mg of prednisolone. In some cases, we consider pulsing them with IV methylprednisolone for a couple of days before switching to all prednisolone. And in cases like this, please discuss with ophthalmology and rheumatology, and we'll be very happy to review the patients. Um, coming back to the physical examination, um, part of the scoring system. You want to see if there's any temporal artery abnormality? So is there any tenderness over the temporal artery? Is the thickening of it? Is there a lot of pulse there? These can all be useful features as part of your assessments. Another I emergency, which needs to be dealt with very, very quickly, which presents with a painful, typically unilateral, painful red eye is acute angle closure, glaucoma. So as I mentioned unilateral, painful I, the patient will often have hazy vision. So because acute angle closure, glaucoma is where the pressure has has risen quite a lot in the front of the eye because the drainage channel between the virus, the colored part of the eye and the front part of the eye it's called the angle has been included. So when this happens, the cornea doesn't. The cornea can't becomes waterlogged, and it becomes opaque over time because the pressure's gone up quite a lot in the eye. The patient may present with nausea or vomiting, or they may have some aching around the eye. And it's an emergency, which we need to manage very quickly. So the key thing is to bring the pressure down in the eye, and the way that we do that is either with oral or IV acetazolamide um, contraindications to this would be if the patients got severe chronic kidney disease or kidney impairment, then we need to consider other medications. You can use mannitol, for example. We can just stick to drops on the eye. You can constrict the pupil. So in order to widen up the angle this drainage channel in the front of the eye, you can get what's called Pilocarpine you can. Doing that will bring the bring the pupil down and help widen up the drainage channel. This is something which you need to urgently discuss with ophthalmology. Um, basically, we we hit it with every single pressure drop that we can get our hands on. Um, so remember some of these can be contraindicated based on the patient's other conditions. So if they've got asthma, for example, or COPD, we might not be able to give certain drops. Um, so it's useful to know that in the history and also, as I mentioned at the very start, it's useful to know whether the patients had cataract surgery in the past or not, as if we removed their own lens. Then the eye has a lot of more space in it, and it's unlikely to do something like an angle closure. If a patient presents with transient visual loss, then you need to consider vascular pathology, so something such as cirrhosis, few jacks or mini strokes can affect the back of the eye and I've seen this. Quite. I've seen this on a few occasions. So just two weeks ago, I saw a patient who had three months history of intermittent visual loss in one eye. So he said that he was losing vision in one eye from ranging from five seconds to five minutes. Um, so five seconds to five hours, actually, um, and I was quite shocked that the patient hadn't hadn't come in together. I checked out because you think if you lost vision in one eye for five hours, you want to get it checked out? But I think the patient had had a childhood cancer and was quite concerned about the possibility of that that coming in the patient was just very, very anxious and hope that it would all blow over. So when I examined the patient, um, the the eye itself was fine, but the history was in keeping with cirrhosis, few jacks or t. I s So in a case like this, you have to refer the patient as soon as possible to the t I A clinic. So in my case, the patient was seen that afternoon in the T I A clinic where they did a carotid ultrasound, and they found out that he had a near complete occlusion of the carotid artery. And we're considering him for a carotid endarterectomy in further intervention. You want to start the patient on on on aspirin? Um, if you if you suspect that it could be CIA or stroke related symptoms. But again discuss with ophthalmology just to make sure that there's no other. There's no other possibility for it. Um, you want to check the visual fields and confrontation because often patients aren't aware that they've had visual field loss. So I saw a patient earlier last week who said that they noticed a bit of haziness in their vision on one side, but he came into I casualty after walking into a lamppost. But he wasn't aware that he couldn't see on on in part of his vision. And when I did confrontation. So when I covered his I just like you would for a neuro exam. So just roughly bring your fingers in from from the periphery and come in words. I noticed that he got homonymous hemianopia so he couldn't see on on one side or both of his eyes, formally assessed it with a visual field test and looked at the back of his eye. His eye exam was completely normal, Um, but just from the history and from him not being able to see on on both sides, the homeowners hemianopia I diagnosed him with a stroke and was able to refer him on two medics for having a CT scan and started management of that stroke. Um, so again, with visual visual loss, look at the patient's visual fields as well. And if it's an acute visual loss, then please discuss with ophthalmology. There's a lot of other pathology affecting the back of the eye, such as an artery occlusion or vein occlusion, or bleeds in the eye that we need to rule out. So again, this is the visual fields of the patient who I saw last week. You can see that the patients lost the whole hemifield on one eye in both eyes, but actually, the ocular examination otherwise was completely normal, so patients may actually may not be aware of the of the visual field loss. All he noticed was a bit of haziness and his vision in one eye, and then he walked into a lamppost, so you can get this in general casualty as well. Um, so rattling through this, um, we have a patient that's looking straight ahead. And in the nine different positions of gays, does anyone have an idea of what this might be? When you look at the patient looking straight forward, as in the middle image, you can see that they've got apoptosis and the eye is looking downwards and outwards. Yeah, I can see you're saying third nerve palsy. Yeah, so it's quite characteristic of a third nerve Palsy. Um, so in in a third nerve palsy, you want to have a look key features to see whether the pupil is involved. So if you if you shine, if you shine your pen torch on there and you see the pupils been affected on that side, um then think back to medical store. You've got your medical third nerve palsy versus what we call a surgical third nerve palsy. So something such as a posterior communicating artery aneurysm putting pressure on on the on the fibers around the around the nerve. The vasculature around the nerve, um, is something that you need to rule out, in which case you need to do an urgent CT angiogram. Get your physical observations on the patient. Check that BP, um, and get the urgent teams involved as soon as possible. So ophthalmology, Neurology, vascular. If need be. Um, that's something which is an emergency, which you need to rule out. There are other nerve palsy, which can present with a patient coming in with diplopia. For example, if a patient has diplopia, what you want to check is, is it just if they cover the other, if they cover each eye at a time, do they still have the diplopia there? So if they cover the eye, if they cover the other eye and they still got diplopia, Um, then there's a problem, which is just affecting that I usually the cornea at the front of the eye. However, if they cover one of the eyes and it gets better when they cover each eye at a time, then it's a problem with the eyes working together. So normally, both eyes should be aligned looking straight forward at your target. But if they look out to the side and one of the eyes doesn't move as well, they may have for example, six Little Palsy. Um, in which case we need to try and figure out why that is, um, so it could be what's called a false localizing or localizing sign for other pathology, like a tumor within the brain, or bleed within the brain or some other pathology going on. But again, if you've got any concerns, just give ophthalmology or flashes. And floaters is something which presents in general practice. Um, a lot of the time these patients may actually just present to their opposition, in which case, they'll they'll refer them on top homology. But flashes and floaters is is potentially an urgent presentation if it's got other associated visual field loss along with it, um, so flashes and floaters can happen when there's separation of the gel at the back of the eye. So within the vitreous cavity, particularly short sighted patients because the eyeball is longer than average, the gel in the back of the eye can start to liquefy, and as it does, it can pull on the retina behind it and start to form a tear in it. And if there's a tear, then fluid from within the gel at the back of the eye can see underneath that tear in order to pull the retina off, leading to a retinal detachment, in which case we have to do some form of surgical procedure. Um, in order to try and put that right. However, if it's quarterly, if there's just flashes and floaters and there's only the start of a tear, then we can usually do some laser ring around the margins of that tear in order to prevent it from getting any worse. So if in ophthalmology, if we see patients who have hot flashes and floaters, we have a good look at the back of the eye, Um and, um, and if there is any signs of any tear, we try and treat that same day. If not, then we always safety net the patient. We usually give them the leaflets, saying that if things get any worse worsening flashing lights, increasing floaters or loss of any part of their vision than to come to I casualties straight away and we'll check it out. There's a lot of these cases you can ask them, ask them to be checked out, either by ophthalmology or discussed with the opposition. All right, So that's quite a lot of the common presentation is that you might see either in general casualty or what we see in I casualty. Um, does anyone have any questions at all? So if you stop your questions in the chart and if one of the almonds can put them through on the put them through on the zoom chart, please. Thank you, Robby. That was a very, very good tutorial. Very comprehensive. Um, I certainly learned a lot from your this tutorial. I think you covered quite a lot of ground. Um, in that hour, as Robbie said, if anyone has any questions, I've got the chart open here, so I'll ask me what they are. We can stay behind another five minutes. Um, but thank you very much. That was a very, very helpful talk right now. There's no question so far, or if anyone had any have any examples of things that you've seen in general casualty or things you see on the ward for patients who complains of heart issues, Then don't feel free to put it in the chat. Okay, so someone is written. Hey, doc. I came across the case that got her I scratched by a cat. What should I have done? There was no redness. There was minimal vision, pain and no vision loss. Okay, um, so if the patients had an abrasion, if they scratch the front of the eye, Um then again, if you can If you do have it, then try and put some pleurisy, then to see where that scratch on the front of the eye is. Um, the main thing really is to cover it with antibiotics. So you start off by giving chloramphenicol ointment, Um, usually about four times a day for about 7 to 10 days or up to two weeks even. And safety net the patient. So if they feel that things are getting any worse or if they've got any blurring of vision, severe pain in the eye, um, then give ophthalmology a call. Sometimes if there's a start of of a of an infection in the front of the eye, if they've got an abrasion there, there could be some inflammation within the front of the eye as well. And again, that's something which we have to do a proper, uh, slit lamp examination in order to check out good and Sara's written fantastic presentation. Many thanks. All right. You're very welcome. My pleasure. Well, lovely. So, everyone, I've got the feedback link here. I'm going to post it into the chat, and we're also going to, um, email it to all the attendees. Um, it would be absolutely amazing if you could. It's very, very few questions. Um, and it will take a couple of minutes maximum. If you could all fill in this feedback, Um, and we can pass it over to, um to Robby. And so he can, um you can see how you guys found the tutorial, so that would be great. And? Well, as I said, we'll email the link around as well as I pasted it into the chat. Um, Susan. Very good. Cheers. Thank you for having us. Um, but yeah. Thank you, Robby. Um, that was very, very good tutorial. And, um, everyone will see you in the next tutorial in this series. Okay. All right. Thanks, Everyone. Have a good evening. Have a good evening.