Computer generated transcript

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

Good evening everyone. Um Thank you so much for joining us this evening. We are, we are now live in this middle primary care um event. We are so glad tonight to have Doctor Michael Williams with us. Um Tonight, we are covering visionary insights, navigating ophthalmology. And as we were just talking before the event there, I was saying how much I'm looking forward to getting up to speed with what's new and a bit of a refresher I think would be good. So, um Michael Williams is a consultant ophthalmologist, um a lecturer at Queens in Belfast and is also in charge of students at Ulster University Medical School as well in the Belfast Trust as you will be well familiar with. Um we will spend approximately 45 to 50 minutes um with the presentation and then we will field our Q and A session at the end. So I would really encourage you, please um put messages, comments, questions into the chat box. Um I'll be monitoring that throughout the session and we will collate together some questions um to have some discussion time at the end. If you haven't already, I've already sent the link into the chat, but I'd really recommend checking out the Med all app and the QR codes for um iphone and Android should be on your screen. Um On the metal app, we essentially have all of the facilities that are used in metal on your browser. You can register for your events, you can get your certificates. And one of the absolutely brilliant new features is um the references section where you can access patient information leaflets um that links out to lots of reliable sources available on the web and it centralizes that. So when you're seeing a patient, you want an information leaflet or you want more information, it's really easy to pull together. As you know, we run free primary care events almost every week. Um And if you're on the app, that will mean you're the first to hear about the new events that are coming up and make sure that you don't miss out. So without any further ado from me, I'm going to pass over to Dr Williams if you'd like to pull up your slides and we will get tonight's event underway. Brilliant. Ok, Tim, hopefully. Is that me sharing that is you sharing? Yep, you are up on presentations there, slides are there joy, folks. Thank you very much. Uh Absolute pleasure to do this. This is a really impressive series of, of events that met all run. It's a great app. I've done a few conferences with me all and it's so user friendly. Um you know, at, at both behind the curtain on stage and also as an attending and, and thanks Tim for that introduction. I remember Tim very well as he came through Queens as a medical student in a good way, in a positive way. It's a very positive influence on all around him. So I hope this is useful. Uh I mean, I suspect uh what I want to do is give a broad sweep of ophthalmology and just share how I organize it in my head. If you like. Uh for some of you, I suspect you'll be saying, well, we know all this um some bits will be useful, but hopefully for some of you, you know, this will be uh as Tim said, a refresher uh with some insights into what's happening. Visionary Insights is the title. I didn't choose that title. I'm not sure I can live up to that, but it's a good title. I'm going to, I'm going to steal it for future talks. There's so little ophthalmology in uh most medical school curricula and this is just some shots showing a part of what we do in Queens, which is the simulated eye clinic, which is an interactive fun exercise with eyes. But um when I was a lad back in, back in the day with two weeks of ophthalmology and now it's a week shared with Ent and yet, um I'd be curious to know how much ophthalmology, you see day to day and, and in fact, in general, I'm, I suppose sharing what I think would be useful for you. But at the end, I really want to know how you, you know, what gaps there were and what you really wanted to know or equally what you find useful. Uh I shared this as a way of organizing epidemiological significance at all. It's not that loss of part of the visual field is more common in Russia. But some people have told me this really helped them organize things because when it comes to an eye case, I think the key is to, to zoom out and categorize it into sudden loss, painless loss of vision, gradual, painless loss of vision, diplopia, red eye loss of part of the visual field. Uh and in the Indian Ocean, then you have a little uh a a few little succinct lists that are just worth learning. So that might help when you think of diprop in Europe and it just might be a bit of a visual association that might help. So let's go through each of these continents or categories starting with sudden painless loss of vision. Um And again, it's not pathophysiologically accurate, but I like to cater sudden painless loss of vision into three groups conditions where there's too much blood, if you like conditions where there's too little blood and other stuff. So firstly, conditions in which there's too much blood vitreous hemorrhage and for each of these, I'll try and go through the symptoms and the signs and the causes and the management, the symptoms. Lots of floaters. Now, I have a few floaters. I've had them since I was about 10 and they're just little wisps of cobwebs that float around. I see them against a blue sky like today where I am and, or a white page and I'm sure many of you have little floaters for me. They're the same old floaters. I'll probably have them all my life and they're nothing to worry about. But if I ever got new floaters, then I should go and see an optician or someone within a few days. Um And with vitreous hemorrhage, typically, there are a lot of floaters. It's not a case of the cobwebs that I have looking a bit more prominent. Uh It's vitreous hemorrhage is like a liquid uh bruise and it starts with that bleed into the eye. So you get a waterfall and patients often describe these blobs of floaters as being red in color. Um And typically after 1015 minutes of these, the whole vision is blocked. Um And so that's vitreous hemorrhage. What does it look like? Tomato soup? I'm very proud of this uh this image that I did all by myself in the bottom, right? Overlaying tomato soup on a photo of the retina. Um And again, it's just an association. Next time you have tomato soup, you can reflect about visual fields. Um And it's hard to see the retina, often impossible through that blood just as it's impossible for the patient to see out. Of course you can't see in. Um And it's a big hot red mess. What causes vitreous hemorrhage? Well, actually, occasionally it's the cause is a retinal tear or retinal detachment. Now, retinal tears or detachments normally present, not with vitreous hemorrhage, we'll come to that. But if someone has a fresh vitreous hemorrhage, especially if they don't have diabetes, you've just got to ask, could it be a retinal detachment? Let's call the ophthalmologist next morning. It doesn't need to be in the middle of the night or even an evening thing. In fact, often a night's rest can actually help the vitreous hemorrhage settle. Um And the, the ophthalmologist will decide whether to do an ultrasound or not of the eye. But the most common cause by far is of course, diabetic retinopathy, specifically proliferative diabetic retinopathy, which we'll come to if someone has a vitreous hemorrhage due to proliferative diabetic retinopathy. What's the treatment? The treatment isn't surgery or drops the treatment? It's for the patient to pretend that they're aged 80 to rest. So they don't have to be housebound or bedbound, but they want to avoid vigorous activity. The analogy I use with patients is it's like a one of those snow globes that you get at winter time that's been shaken up and you want to put the snow globe on the table and let the vitreous hemorrhage settle with gravity just to mix metaphors there. Um And, and usually slow over a few weeks or a month or two. Usually it, it feels like a bruise, it's absorbed and it settles with gravity. Um So yes, they can be out and about, they can be reading, they can be watching TV, but they want to stop dancing or jogging or whatever they're into until it settles. OK, sudden painless loss of vision. Uh Another cause when there's too much blood is wet, macular degeneration. And so this elderly patient typically can happen 60 plus people. Um and typically sudden loss of central vision and specifically difficulties reading or seeing faces as and as I'm sure many of you have experienced talking to patients. Actually, it's interesting, often patients happen to cover one eye and they suddenly notice that the vision is down in one eye. It's amazing how people can have quite poor vision in one eye and not notice when they're going around with both eyes open. Um I have a pet theory that women present a bit more uh a bit earlier than men because women are more likely to put on eye makeup. And I've certainly had a few female patients saying as they put on their eye makeup, they notice as they close one eye that the vision's down and the other eye DRS and our little yellow spots in the macula, they are sometimes called ir macular degeneration, but I think of them like gray hairs in the retina. Um They're just a sign of aging really. And the more dru you have the greater the risk of progressing to wet or dry A MD. But most people with dru don't ever progress to wet or dry AMD and dr don't need treatment. They don't affect day to day vision, you couldn't treat them anyway. Um But normally when there's wet or dry MD, there's a background of Dr if someone has who's 70 plus has central visual problems, you see Dr and what is the key sign that tells you that it's wet, macular degeneration. The key sign is blood and it's easy to remember cos blood is wet. So yes, we do our OCT scans in the eye clinic that feels like cheating to get this lovely high res cross sectional image of the retina. They are wonderful scans. Um And occasionally we do angiography. Um But normally if you see blood diagnosis is nailed and it's worth recognizing because they need treatment within ideally two weeks. Um And the treatment is in the form of intravitreal injections of anti vegf S anti EG FS, which you can talk more about if you want. How do I describe them to patients? Uh Well, I said, cos they sound terrifying. We're sticking a needle in your eye, but the way I describe them and I think it's accurate is to say, look, it takes five minutes. The 1st 4.5 minutes uh involves lots of eye drops and a few stickers around the eye, eye drops to numb and to sterilize the eye. And the injection itself is literally about half a second. And most people feel a pressure and that's it. Occasionally people say that was sore but it was only half a second. And occasionally people say I felt nothing. Did you even do it? Um But most people literally walk out of their first injection saying was that it? So um they sound a bit disappointed but uh once they get their first injection over, they realize it's nothing to lose sleep over. I know it's easy for me to say, what about the risks? Well, because we're putting a needle into the eye, there's a small risk of introducing infection or causing bleeding or high pressure in the eye or other problems, all of which can blind an eye. But the rate of infection is about one in 3000. So these complications can occur and they do occur, but they're very rare and left untreated wet, macular degeneration will lead to a scar in the macular and permanent central visual loss moving on uh and retinal vein occlusion. Uh I won't dwell on um it uh in my mind, the the signs are very much like a pizza, lots of food and allergies tonight. Uh I hope I'm creating useful associations and not putting off your food. Um but it, it, it sort of in a way looks like uh diabetic retinopathy, but only in one eye. I in a way, there are multiple hemorrhages, sometimes fluffy white cotton wool spots, that's the mozzarella cheese uh and sometimes exits um and just like diabetic eye disease. After retinal vein occlusion, there are two complications that can occur. One is macular edema. The other less commonly is um new vessels, neovascularization on the retina will come to that. But ii suppose for primary care with retinal vein occlusions, the Royal College of Ophthalmologists recommends a check for BP and a check for diabetes. I think are useful for anyone. They also recommend F BP and E sr Well, I'm not sure we normally used to ask the GPS to do these blood tests and they very kindly did really. They used to look for things like leukemia or vasculitis, but I think a good history should be able to exclude those. Um Certainly checking BP, checking diabetes, essential after a retinal vein occlusion. Ok. Uh Tim, I'm poor keeping track of time here. I hope this is going all right. Um But you can tell me to hurry along as needed. No, you're absolutely top class or, or slow down as needed. All good. Thank you. Um If I'm suddenly thrown out of the meeting, I I'll know it was Tim and I've done something wrong, sudden, painless loss of vision then after things with too much blood, things with too little blood. If you like central retinal artery occlusion, sudden loss of vision like that really like a black curtain coming down. Amaurosis. FXX is where this happens. But the vision lifts within five or 10 minutes. And this is of course, because of a clot passing from somewhere. Typically, the carotid artery to the central retinal artery with aosis FXX like a tia a the clot moves on down the retinal arterial tree. But with a central retinal artery occlusion, the clot stops and um when and the key sign is a cherry red spot. And you can see there in the middle of the fovea next to the disc, there's this red spot. Actually, it's interesting that red spot is the normal retinal color. It just stands out because in the days after this happens, the retina becomes swollen and pale. And so the pale retina looks pale but the f at the fovea at the center, there is nothing to swell really. And so that remains its normal color and hence the cherry red spot, the treatment for central artery occlusion. Well, unfortunately, there's no ocular treatment. Lots of things are tried and they have to be tried within 24 hours, ideally, within six hours. And they're designed to try and crash the intraocular pressure down, which in theory, mechanically allows the clot to move on down the arterial tree. I've never seen it work, but it's always tried because if more than a day has passed really, it's, it's not worthwhile. Um And so we give IV Dye marks, for example, vigorous ocular massages done once I've seen a aqueous be removed when it was an only eye to crashed down that pressure. Um But what really is important is a cardiovascular workup. And I send these patients to the neurovascular clinic. Uh and they, and after, unlike a retinal vein occlusion, when uh which is not an indication itself for aspirin, a retinal artery occlusion is an indication for aspirin. Ok, sudden pen loss of vision when there's too little blood, this big mouth full of anterior ischemic optic neuropathy, which really is like a stroke of the optic nerve. Most common cause isn't what's shown here. The most common cause is just uh cardiovascular risk factors. So you're elderly hypertensive smoker. So again, managing cardiovascular risk factors, this patient crucially will, well, they'll have a both these cases, actually an A PDP defects and and actually sometimes hypotension at night, nocturnal dips in BP at night can also compromise the optic nerve and effectively cause it to stroke out as well. So, careful management of BP uh is easier said than done. But um it it's probably worth looking at that. Um This picture is of a temporal artery biopsy because a less common but must never miss cause of anti ischemic optic neuropathy is of course temporal arteritis on the side. Let's look at causes of optic disc swelling. When I'm looking at an optic disc, I think of color contour and cupping. If I go two slides back, just to show you, I don't think you can see my cursor. But if you look at this optic nerve by color, I mean the color of the rim. So every optic disc has a pale cup in the center and a rim around the edge. And in this case, in this photo, forget the cherry red spot we're just looking at at this disc and the rim is orangey, which is normal. The other uh color you might see is pale, which is atrophic. And of course, there's a spectrum in between but color contour cupping by color, I mean color of the rim. And it's a good starting point is it's one of two things orange which is healthy or pale, which is atrophic cupping will come to and contour refers to the edge. Can I see uh the edge of the disc distinctly? And contour is one of two things, it's either distinct or indistinct. And if it's indistinct, that means the disc is swollen. And here are the causes that word papilledema gets thrown around to mean optic disc swelling. But actually, papilledema specifically means optic disc swelling due to raised intracranial pressure like a space occupying lesion or I IH. And so it'll be both discs swollen. Anti ischemic optic neuropathy will cause disc swelling whether it's the anti the elderly hypertensive smoker or whether it's temporal arteritis, optic neuritis in, in uh like in sometimes in uh MS will cause disc swelling and central retinal vein occlusion when you have hemorrhages right out to the periphery as well. That's on the side, that's optic disc swelling. And in this picture, you can see the contour is indistinct. I can't identify a the the margin of that optic disc. Therefore, it's swollen, super, all right and sudden pain of loss of vision, other stuff I retinal detachment. Uh And in this photo, you can see the top half has blurred and that's because the wallpaper is peeling off the wall. The retina is detaching, it's falling off the wall behind it effectively. Somewhere up there, there'll be a tear and it's like a tear in wallpaper fluid can get in through the tear and start to peel the retina off. And so this patient typically, uh a myopic patient will have a shadow progressing up from the opposite side of their visual field. Ie in this example, from the bottom of their visual field over a few days typically, and eventually the whole retina will come off. Um How does this happen? Well, it happens because of posterior vitreous detachment every day in opticians. And I certainly used to be an eye casually. We see patients with floaters and flashes, new floaters like those cobwebs I described and flashing lights like there's a camera flash going off in their eye and usually it's because of a normal process that happens, I guess in all of us, of the vitreous jelly collapsing in, in itself. Um And that's normal. It's not even really a middle age thing. It can happen at any age, but, uh, you know, in life really. Um And actually as the vitreous collapses, it falls off the retina and it pulls on the retina bit, that's what the brain interprets as flashing lights that traction and the floaters are wisps of condensed vitreous that then stay around. Normally, it pulls off the retina and causes no problems and the flashing lights stop the floaters last forever. And once you get that posterior vitreous detachment over with safely, you can breathe a sigh of relief because occasionally as it pulls on the retina, it pulls a tear in the retina and that's how most detachments happen. So that's retinal detachment. The treatment is surgery, really amazing surgery to watch. Uh really wonderful stuff. Um which in most cases work. But of course, there's, there's no guarantees. Ok? I, I'm throwing past, uh I know and a lot of information coming to you, but hopefully these broad cans will help. As an aside, I guess two causes of sudden loss of vision with pain optic neuritis. And just for the record, if you hear someone talk about retrobulbar neuritis, it's the same thing. It's just an optic neuritis. The optic nerve is inflamed at the disc. And so you can see the swollen disc, retrobulbar neuritis is exactly the same thing, except the inflammation is further down the optic nerve. So when you look in the optic nerve head, the disc will look normal. And if someone has optic neuritis, certainly, when I started, you may or may not do an MRI head to look for MS these days, you definitely do because you know more about this than me, but there's disease modifying treatment for MS. So someone presents with neuritis. Obviously, I take a history looking for remote neurological episodes which themselves could pretty much clinch the diagnosis. But even without those, I would do an MRI head and I would tell the patient there's a chance this could be MS because they look it up and see that immediately. So I I'm going fairly quickly here and Tim can tell me off later if it's too quick. But I thought just a relaxing photo to take a breath. Actually, I don't even know where this is of, um, it might be a place where they paraglide in the near Limavady, but I, I'm not sure one of you may know. So that breath, let's look at chronic painless loss of vision. And so these categories aren't quite exact. I know, but here we have dry or atrophic A MD and for wet or dry A MD, what causes these wet or dry A MD? Uh Three main risk factors are obviously age which you can't reverse family history as well, which you can't reverse and smoking. So I do warn people all the time in eye clinic about smoking and advise them to cut. I like to think that the surprise of been told in an eye clinic that smoking can be a risk factor for macular degeneration. Uh It shocks them into stopping. I'm probably naive in thinking that, but at least I, that's the message I promote and dry MD is interesting because it starts with little pockets of atrophy of the photoreceptors and R pe around the fovea for some reason. And then over typically 2 to 5 years, sometimes longer, they gradually enlarge and coalesce to form a circle or patch of atrophy in the middle. And the patient will have a corresponding blind spot in the middle of their vision, the patch of atrophy, if it helps you remember, this is often country shaped, I often try and equate it to the shape of a country. I mean often the squarish countries, France, you know, Poland, it's like um I mean, it's never like Sweden or Norway, it's normally kind of roundish and it is called geographic atrophy. The treatment for dry A MD is interesting, supportive treatment really matters and this is done via in where I work and in the NHS in the UK Angels we have in the eye clinic called eye clinic Liaison Officers. Um Again, when I started with someone with this we would just say there's no treatment for this, go and see your GP. I mean, I wouldn't be that blunt but that was the message, but now we can hand them into the arms of the EC O the site support worker who are funded by the NHS and the RN IB. And they can signpost and refer to all these supportive services, practical support at home, social support, financial support, uh the low vision clinic for magnifiers and all these things and registration. Of course, if it's appropriate and all these things can make a difference between someone being able to read bills or cook and therefore stay at home or not. Interestingly, there is an intravitreal injection of a complement inhibitor licensed by the FDA and being used probably now for a year and a half in the USA. It slows down the rate of progression slightly and nice are looking at it uh in the UK now. So that'll be really interesting. Uh if and when it comes, I mean, it's gonna help some patients if you have these little circles of atrophy around the phobia and you, you give this treatment, I if you can get a few extra years out of central vision clearly, that really matters for some people. Um But if your central vision is already gone, it's too late. So um that's a chore it's called and it's interesting. Um but you know, it's the start of something in 5 to 10 years, there will be treatment. Um Again, if it helps you remember, I've heard the analogy used of a hole in the carpet of the retina, but I don't really like that analogy cos it implies to the patient that they've overused their eye or the retina and worn it out and you can't overuse the retina. It doesn't matter whether you point it at a wall or point it at a book, you know, you can't overuse it. Ok. Chronic painless loss of vision, we have open angle, glaucoma and glaucoma is just where the eye pressure is high enough to cause damage. Now, glaucoma experts will take issue with that. They'll say it's an optic neuropathy often associated with raised IOP. But I think a good way to remember it is where the eye pressure is high enough to cause damage. Three parameters matter. First of all, the eye pressure, normal range 10 to 21 but it's a normal distribution. And so yours may be seven and that's normal for you and mine may be 24 and that's normal for me. Second parameter is the cup to disc ratio, which is the proportion of the vertical diameter of the whole optic disc rim edge to rim edge that's taken up by the cup. So if we look at these two optic discs here, just as you look at the photo, the one on the left, what's the cup to disc ratio? About 40% or 0.4. And the basic rule is that general 0.6 or less is probably normal. So this is probably OK. On the right, you can though answer to this ratio is probably point but 90% of that diameter rim to rim is taken up by the white cup and over 0.6 is probably glaucoma. So that's coping. So you say to a patient look, your intraocular pressure is 35 your cup to disc ratio is 0.8. The patient goes. So what? Um because glaucoma has no causes no symptoms uh until advanced stages. The third parameter are your visual fails because glaucoma eats away at the periphery and over many years if untreated, um eventually it, it would encroach and cause tunnel vision and eventually blindness, but normally it's spotted and treated um often spotted incidentally. What is the treatment? Well, there are a few options these days. The the world of glaucoma treatment has opened up. Uh It always used to be and usually still is eye drops, prostaglandin inhibitors. Once a day drops, they make your eyelashes longer and darker. Occasionally. I see people on TV. And you can tell they're taking a prostaglandin inhibitor and it doesn't cause any problems. It's an interesting thing. Uh If it's one eye, it can be a cosmetic problem, but I've never met a patient who, who minds this. Um uh If that's not enough, then other classes of drugs can be added. There are four classes of drugs. I'll mention the second one, which is beta blockers and I mention those because there's some systemic absorption. So if someone has COPD or asthma or I guess heart block, um, then you wouldn't be giving them a beta blocker eye drop, we would move on to the third category. SLT laser is a new first line option that's been done for many patients. Sometimes they still need drops afterwards. Um, but it, it's a really great development of evidence that SLT laser can work as a first line agent. Um, surgery can be done, of course, Trabeculectomy. And there's a new class of surgery called migs minimally invasive glaucoma surgery. I'm not get into, but it's an interesting world in glaucoma these days, you can't reverse any damage. You're not going to win back visual fields, but you can halt it in its tracks. So certainly effectively slow it way down to the normal, you know, rate of age related decline that we all have. And I guess like hypertension treatment, you, you guys may be used to this, but it's a hard sell because the patient comes in with no symptoms. And you're telling them you have glaucoma, here's an eye drop, it won't improve your vision, but you have to take it every day for the rest of your life. It can be a hard sell and of course, cataract and the top you see cataract here and the bottom. You see uh the treatment, um, what causes cataract age and the way I describe cataract to patients is just that the lens in the middle of your eye, which is clear when you're born fogs up in everybody as they get older and it doesn't do any damage or harm. It just means that instead of looking through a clear window, the window is fogging up and the only treatment anywhere in the world is surgery. But the only reason to do surgery is if, uh, you want it, if the patient wants it, it's not to do with the grade of cataract or the visual acuity. Um And, uh, thankfully, we're not bound, you know, financially by those structures. It's certainly where I work. And so a patient may have 6, 12 vision but be really troubled by their, their cataracts because maybe they're doing lots of fine work surgery can be indicated, someone with kind of 6/24 vision, but maybe they're elderly and their only needs are to watch TV and recognize family and cataract surgery isn't indicated and that's all good. It's not that we age just by the way. I mean, arguably the reverse is true. Vision becomes more important as you get older and, and your mobility declines and your cognitive abilities decline. It's important to have good eyesight to remain orientated and so on. Um, and we've had two patients who were 100 and four who got cataracts done as long as the patient can lie fairly flat and still for about 20 minutes, they can get their surgery. Ok. Diabetic eye disease. This could take a whole four hour itself. Um I just wanna go through a few things. There are two, the way I think about this a diabetic eye disease is there are two different things that can happen. Although they normally coexist, like I mentioned with retinal vein occlusions. The first is macular edema in the side on the top right, you can see here a circle of yellow stuff. This yellow stuff is exudate. Is there macular edema. I don't know because it's a photo but actually it is like a tide line and it tells me that there is fluid or there has been fluid there, there's a leaky point in the middle and you get a tide line around this puddle of macular edema. What is the treatment for diabetic macular edema? The same as the treatment for wet A MD anti VGEF injections. And by the way, these injections, it's not just one injection, people often get these injections on and off for years and every uh clinic indeed, different drugs will have different regimens for how often it's given. So that's diabetic macular edema. The other thing is uh retinopathy. And so while maculopathy refers to stuff in the macular in the middle retinopathy refers to stuff in the periphery. I should think of a better word than stuff pathology signs whatever. Um and So, retinopathy is two stages, nonproliferative and proliferative. So, previously, people talked about background and preproliferative and that's fine but easier to have two categories. Non proliferative, key signs are dot and blot hemorrhages and cotton wool spots. What's the treatment? Manage the risk factors for progression? What are those risk factors? Well, there are three groups of risk factors. Firstly, the two headlines independently important of managing blood sugar and BP. The second group of risk factors are lifestyle stuff. So uh weight, diet, smoking and exercise. And the third category are things people always forget. So what are they? Well, pregnancy and in pregnancy, for some reason, diabetic retinopathy can race on. So, ideally, before planning a family, someone should, a female patient should optimize the other risk factors. Of course, that's often not uh doesn't happen and not possible. And so people just need seen more often if they're pregnant and have uh diabetes and any diabetic eye disease. Um and the other thing people always forget is screening. So, you know, if you can remember one thing from tonight's talk and you go in next week, you're remembering this talk. Just remember to ask every patient with diabetes that you see. Have you had your eyes checked in the UK, there's the UK screening program and some people attend their optician instead and that's fine as long as they do so faithfully every year or two. And of course, there's a core of patients who don't get their eyes checked, who are the hardest to reach and probably the most in need of getting their eyes checked. So that's the three groups of risk factors that apply to any stage of diabetic eye disease. But in most people, this doesn't happen. But in some people, eventually, new vessels form and the bottom left shows this seaweed frond of new vessels. There's a picture of seaweed. So next time you're on the beach having your tomato soup, you can look at seaweed and think about new vessels and ask yourself what symptoms do new vessels cause trick question because they cause no scent until or unless they bleed. And hence the UK screening program because uh you know, every, every month, every week, there are people with new vessels who knew nothing about them because they hadn't bled yet. And so what's the treatment? The treatment is laser as shown in the bottom, right? These black lines in the bottom are just eyelashes, but you can see all the white spots evenly spaced, uh beautifully spaced around the edge. Patients often think you're welding the new vessels somehow, but you're not, you're, you're really um lasering ischemic retina all the way round. And the important thing is the effect is to make the new vessels regress. Does this damage peripheral visual fields? Well, yes, the spaces between the dots there mean it shouldn't have any day to day effect on your peripheral visual field. But if people get a lot of laser to both eyes and start to become confident, then yes, they will start to notice reduced night vision, reduce peripheral vision. Um But uh normally it doesn't affect day to day uh peripheral visual fields. And certainly that's lesser evil than letting new vessels continually bleed and scar because that blood will, if it's recurrent, will eventually lead to scar tissue that can pull the retina off. Um So PRP is a very effective treatment. Um And so that's PRP, if it helps you remember this, uh then so don't do this. But if you're doing laser, but you could write your name and laser across the patient's retina, um don't do that. OK, red eye. And if someone comes in uh with redness, watering or photophobia, of course, it points to front of the eye problem. Sometimes the problem is obvious and occasionally it, every five or 10 years, we have this problem. This is interesting because the end is barbed. So you can't pull it back through, you have to cut it and make a second and kind of feed it through anyway. And some of the the kind of most painful things for patients often and are actually the most beautiful things aesthetically if you like. But this is how I think about red eyes, five causes of red eye. And I guess, you know, this is from the hospital point point of view. I mean, you may reverse this but I suppose we all see red eyes presenting acutely. So let's go through these. The two headlines start with endophthalmitis, um, symptoms of pain redness blur and the key sign is the hypopen H YP Opon. That word that people can never quite remember and never quite spell, but they know what it is. And it's as shown here, this little layer of pus that over time would build up in the front of the eye between the iris and the cornea like at the bottom of a, a fish bowl. And the basic rule is if you see a hypopen, it equals endophthalmitis. And we certainly want to see that whether it's three in the afternoon or three in the morning. Um What causes this I do or someone else giving an injection into an eye or doing intraocular surgery. Like I said, the risk is about one in 3000. Occasionally, there are other causes, traumatic causes like rose thorns and very occasionally interesting causes like endogenous and ophthalmitis from an infected heart valve. But normally it's or intravitreal injections. And the treatment then for the poor patient is to stick two needles into the eye, one to get a sample of aqueous and or vitreous to send to the labs for culture, et cetera. And the second needle is to give an intravitreal injection of antibiotics. Empirically chosen. The outcome depends on the Vence of the organism and how soon they're treated. But, but time does matter glaucoma, as we said is just when the eye pressure is high enough to cause damage. The other type of chronic open angle glaucoma doesn't cause symptoms, acute angle closure, glaucoma is very different because the eye pressure goes up so high, so quickly, it causes symptoms. This patient is really sore. They're nauseous, they're throwing up and they're um they've got halos or eye lights. Um, their eye uh is firm to touch and the cornea is hazy. Uh So, I mean, the signs are, they've got a red eye, the cornea is hazy. The eye is firm to touch. If you squish your own eye do, don't do this too hard, but there's a bit of squish ability to it slightly. Um This eye will feel rock hard. So if you can't uh measure intraocular pressure precisely, you, you, the patient might allow you to press their eye gently and this will be rock hard. Um The pupil is fixed and dilated and we'll come to this in a second. Um And so, you know, there are urban myths, although one of my colleagues says this happened in Birmingham of patients with nausea and vomiting, admitted surgically, tummy, soft, inflammatory markers, normal, scanning, normal, literally about to go for laparotomy because they were still vomiting when the F one noticed the red eye and felt the eye rock hard round to eye, casually, acute glaucoma diagnosed. Um And so this can blind an eye overnight. Again, we'd want to know about this uh immediately the treatment is medical treatment to lower the eye pressure, um with drops and IV dye marks and steroids as well. Uh steroid drops and ultimately the curative treatment that we do as soon as we can occasionally, right at the time, often in the next few days when the cornea clears a bit um is peripheral laser iridotomy. So autotomy means make a hole in iridotomy, make a hole in the iris laser iridotomy. We use a laser to do it. And peripheral laser iridotomy, we do it out in the periphery, always usually superiorly. So it's hidden by the, the eyelid and it's like a second pupil, except it's very tiny, you wouldn't really see it if you were the naked eye and often we do two. And this allows the aqueous which is trapped behind the pupil to rush through and it's a lovely procedure to do uh rather disgustingly. I've heard it compared to being when it, when you get through the iris. After a few shots, there's a gush of aqueous comes towards you. And I've heard it described like being under a flushing toilet, which is pretty disgusting analogy but memorable and it's lovely. The iris goes back and you can almost see the whole eye with a sigh of relief and you do it to the other eye too. Um Because if one eye is prone to it, um the other eye will be prone to it too because there are two risk factors, age and both eyes are the same age and hyper metopia. Longer word than myopia. Hyper metopia means long sighted. And usually if one eye is longsighted, the other will be to. And once the laser is done, it should never occur again. Orbital cellulitis, I'm sure you see plenty of preseptal cellulitis with orbital cellulitis. The infection isn't just superficial, it's in the orbit, not in the eye but around the eye in the orbit. And it actually has typically come up from a sinus, uh occasionally from dental work. And this patient has such tense eyelid, they're physically difficult to open, but you need to try and open them to try and test vision and eye movements and pupils because this is vision threatening because of the pressure there that can compress the optic nerve. So you want to get a sense of vision and pupillary reactions and eye movements and these patients tend to be sick. Um They're systemically unwell. E SR and C RP are op they need admitted for IV antibiotics and a CT as well because occasionally there's a localized abscess in there that needs treated trauma goodness. Another topic that could take up a whole lecture. I'm aware of time. 2014 and so corneal abrasion shown in the top left. Um and this will heal in a few days uh with topical antibiotics, um which prevent infection but have a lubricating function. But the patient will be sore for a day or two dark glasses, dark room are all you can do. We dilate the pupils sometimes just to relieve some of the the pain. Um, if someone thinks something is blown into the eye and you don't see a corneal foreign body, don't forget to look under the eyelid shown on the bottom left because as you see, there could be a little speck of seed or soil or metal or something under the eye lid. And if you don't look, this patient in the bottom left will come back the next day having blinked all night and scraped this thing across the corneal surface and have what's called an ice rink cornea with zigzag abrasions and they're very easy to sweep off just with a cotton bud, a fema shown in the top middle from blunt trauma, indoor football classically. Uh and the treatment is uh to call ophthalmology because the eye pressure can be raised, but essentially to treat any eye pressure problems, but to rest until it settles. And of course, in the bottom, you see a perforating eye injury, the iris a bit like the omentum is plugging the wounds there. But this needs repairs, obviously because it's a portal for entry of bacteria. And if someone has been hammering or chiseling and they think something's hit, have a very low threshold for suspecting an intraocular foreign body because with hammering or chiseling, slivers of metal come off. So quickly and they're so fine um that you might not see them depending on their energy, they could have gone through the, the cornea, the lens, the vitreous and as shown in the bottom right landed on the retina and you can see this bit of metal uh on the left of that photo having landed on the retina. And of course, this, the scan at the top shows that little white opacity at the back of the eyeball. The the investigation of choice is orbital x-ray eyes up, eyes down or um or a CT and not MRI because an MRI will identify whether there's an inner metallic flea and make an attempt to remove it but not in an ideal way, eyelid lacerations. What we want to know is is it through the margin or not like this cut goes horizontally above the eyelid margin and then in the middle of the eye, it comes down and it looks like it's pretty clearly through the margin. And that requires ophthalmology or plastics to sew together if it's not and also be aware of potential for trauma, of course, to the underlying structure. Ie the eyeball, if someone's sustained that degree of trauma, is it just the eyelid or is it the eyeball as well? And the bottom, right, chemical injuries, irrigation on site immediately is the key. And in this eye, although it's not red, actually, the fact that so white is a worrying sign that the chemical has burnt off the vessels and this is a worrying long term sign, they still need irrigated. But if it's severe like this and the eye looks white, um then certainly AAA call would be appreciated. And so red eye. So we have the two headlines, endophthalmitis caused by people like me acute glaucoma where the patient's throwing up fixed dilated pupil, orbital cellulitis. It's not like preseptal cellulitis, orbital cellulitis. The patient is sick. Um And then we have trauma, whole gamut. Don't forget, subtarsal foreign bodies, don't forget hammering or chiseling. And then uh the itis is you can think of any part of the front of the eye and add the word itis conjunctivitis. It's normally viral, it's sticky. Um If it's not settling after two weeks, sometimes you swab for chlamydia. The treatment is symptomatic cool compresses, ocular lubricants remembering it's contagious scleritis is interesting. The patient with scleritis will spontaneously and this happens again and again, with patients with Ris describe their pain as 11 out of 10 severe pain and worse at night. Typically, for some reason, I don't know why. My pet theory is because people are lying down at night. There's a bit of dependent edema and the sclera is such a small structure. It doesn't take much dependent edema in an inflamed area to cause swelling and, and pain. But who knows. Um But the treatment is usually systemic, certainly, uh topical steroids and oral nonsteroidals can be enough. But people do sometimes need oral steroids or more for scleritis. Um and in half of cases of sclerisis, there's a systemic association classically rheumatoid but citi so we always want to check renal function. Anca ESR and CRP is there vasculitis keratitis refers to corneal problems. We're talking about bacterial ulcers or herpetic ulcers, bacterial ulcers. You can see with the naked eye white areas in the cornea classically associated with contact lens abuse or mis wear contact lenses are fine, but they are associated if misused with a greater risk of bacterial keratitis. And the treatment is to admit the patient scrape the ulcer which is literally a scrape, it's not as painful quite as it sounds to get a sample for the labs and then marinade the eye and antibiotic, eye drops literally every 30 minutes for 24 hours. And of course, viral keratitis is that beautiful dendritic pattern you see in herpetic keratitis and then iritis in the bottom, right? But that's a slit beam of light like a shaft of sunlight shining across the aqueous humor. And the light on the left is where it's hitting the cornea. The light on the right is where it's hitting the lens. And in between you see this dust and these are actual white cells floating around the aqueous. So it's rather beautiful and you know, I'm going to talk about diplopia but I sense the time and I'm going to stop there actually. Um I wanna get to the last slide because I, yes, well, the second last slide, uh I think we have problems examining eyes. Uh Well, maybe there's a problem to you, although this dog looks very compliant. I'd love to hear your experiences and comments though and there's my email address, feel free to email me with comments, thoughts um and so on. Uh M dot Williams at QB dot AC U UK and I'll stop sharing 10 back to you. Thanks Dr Williams. That was absolutely fantastic. Um I really, really enjoyed that. I loved the overview. There was some absolute memory sparking back in my head. I have to, I have to in the interest of full disclosure. And as you said, um Doctor Williams taught me everything that I know ophthalmology as well. So I have to, I have to give credit where credit is due. Also. Um I'm going to pop up just a QR code in the background here as we move into um the Q and A and there have been some absolutely brilliant questions coming in there as you've been speaking. Um Doctor Williams. So we'll just pop these up on the screen. Um Lie is asking about the best way to diagnose and the timeframe with regards to temporal arteritis um in order to prevent blindness, how sort of long do we have there? And what's the key things that we're looking out for? So, uh history, we see it with sudden visual loss with that anti ischemic optic neuropathy and the patients are uh you know, unwell, they're tired. If you ask everyone here, we'll all say we're tired. But these patients are so tired, they, they're not going to the church or bowling or pub or whatever. They normally do the temporal headache. The books talk about jaw cla I've never heard, seen that reported as a s dentures or temporal arteritis can cause that temporary tenderness as well. You, you do see raised ASR and CRP and if clinically sometimes it's considered that's enough information. Uh put when put together to say this is temporal arteritis, let's treat. Um And you can certainly treat for up to two weeks and still have a useful temporal artery biopsy. The treatment is with IV or oral steroids um high dose. So if you're, if we're in doubt and if we think this adds up to temporal arteritis, we'll start treating really as soon as possible. And uh do we always do a temporal artery biopsy? No. Um I if the diagnosis is clinically uh sound enough, we don't. Um But obviously it's the gold standard diagnosis unless you get a skipped lesion. Brilliant. Fantastic. Um ally's also asking interestingly post COVID and I know GP colleagues are seeing a lot of this and numbers potentially growing. Are there any links to eye diseases, eye um symptoms with long COVID that you've heard of? Interesting. Uh The civil answer is no, not at all. Um There was a suspicion that COVID was associated with increased risk of retinal vein occlusion, but that hasn't been shown to be the case. And so no lie. Ok. No, perfect. No, that that's good to know, good to know. Um in terms of retinal detachment, what is the urgency, how soon do these people need to be seen? Rosette has asked next day? I mean, that day or the next day, but if it's getting out of hours a night's rest is perfectly fine. Excellent. Can I just highlight one comment that's just come in that I'm not going to add to the Q and A saying about this being the best ophthalmology teaching, um that RAND has ever had. So just, just to let you know, um, fantastic. I had a quick question if everyone doesn't like me, but then, um, are there any correlations with chronic vision loss and computer phone screen use? Obviously, nowadays, we're all spending a lot of time on our computer screens. No, not in adults. And I mean, I tell people and I don't do this, but especially people with dry eyes. I tell people to set an alarm for every 20 minutes and just blink, sit back for a couple of minutes, look out a window because, um, eyes can dry out when you're staring at a computer, you're blinking less often when you're concentrating. Um, but it doesn't do any harm for sure. It's interesting though in kids, there's said to be an epidemic of myopia because in Children aren't getting enough outdoor time and are spending too long on devices. And this promotes myopia and a certain very small proportion of people with high myopia will get medical problems because they are so short sighted. That's really interesting actually. Um Thank you. Good to know. Um Jenny has asked with regards to the treatment here for glaucoma. What actually is the rate of systemic absorption for beta blockers? Are they just a caution for use in asthmatics, for example? Or are they totally contraindicated? Is there sort of a, a cut off for that at all? Yeah. Good question, Jenny. I can't quantify it. I must say we just avoid it. I mean, often we see patients who had a bit of asthma as a child and they carry they've grown out of it and that's ok. Um So I guess the answer it's maybe frustrating. It's not what you want, but the answer is there's enough absorption that I certainly avoid beta blockers if someone's still using, you know, preventer or AC O PD. Sure if somebody's still reliant on those um lie again has asked and I know there probably are different guidelines based on where in the world you're watching from. But at what stage would we advise patients to abstain from driving from a vision point of view? Yeah. So driving is the one time in the UK when we test vision with both eyes open because in the UK, you only need one eye to drive legally. So if you can hit the sweater with both eyes open, you can drive legally. Uh Also you need enough of a peripheral field as well, but that's less often an issue. But I do see patients in the macular clinic who are below the legal limit for driving. And II tell them this, that I don't set the limit, it's set in law and it's, it's time to hang up the keys. And I say it very sympathetically, it's a huge thing to say to patients. Thankfully, often they've realized or they've stopped. If it's cataract causing it, then hopefully if they get something reversible, reversed, like cataracts, it may come up into the legal driving range. Um But um so there's two criteria, central vision and peripheral vision and it's defined in law in the UK. I didn't actually realize it was both those factors and I know it has such a great effect on people's independence as well. Um Raj has asked, um are there any relationships between systemic BP and eye pressure because they have experience of seeing 24 hour BP cuff studies being done for patients with glaucoma. Uh no, not directly. Uh you know, BP affects perfusion pressure, but there's no relation between uh BP and eye pressure. Um high BP, of course, is a risk factor for vascular eye problems like retinal vein occlusion. I guess 24 hour BP would be done in glaucoma because in normal tension, glaucoma where you get glaucoma, but the eye pressure isn't really raised. It's thought that again, nocturnal dips in BP might be damaging the optic nerve. So that's why that would be being done. That's where that's come from. Sure. Um Akash has asked, is there the relationship between intracranial pressure and intraocular pressure? We've been talking a little bit about pressures. Um No, there isn't, but uh raised intracranial pressure will cause optic disc swelling. Um And so, you know, if someone has papilledema, we have a pathway where we get them scanned to look for a space occupying lesion. Of course, we have many patients, we have many patients with idiopathic intracranial hypertension as well. Um But, but no, they're not directly related to cash. Sure. Um I'm actually currently working on Respiratory ward, but believe it or not, um I had a, a drug rep giving a talk just this week about chronic disease management in primary care. And how big the prediabetic population has got. Is there a role for diabetic eye screening for these patients? Um I don't know for sure. Actually, I don't think so. Uh It's, it's probably a bit of a gray area actually, I don't know, you know, I'll ask a colleague that my answer would be. No. Uh but, you know, I'd have to solidify my knowledge of what prediabetic means. Um So, uh Yeah. I mean, if you really want to know the answer, email me and I'll get back with the answer from my colleague, I think. No. Um, sure. No. Absolutely. And I mean, I suppose maybe it's not black and white either, I guess. Um, Rosette is mentioning a patient having lost vision after starting Finasteride and having to have a surgery the same evening. Would you know what that is? And if it's quite rare, uh, e surgery, not sure, perhaps. Um, that's all we've got sort of ee surgery. I don't know, rosette if you're still on, if you want to pop another message in the chat, we can maybe clarify that. Um, but in the interest of time we'll move on. Um, I think we have kind of covered this hopefully and if you need to, um, er, or anyone else thinking to see him, um, to go back and listen to doctor Williams over again about differentiating between the different it. Um, I know it can be difficult. Yeah, I scleritis, I don't mention, but it's funny, it, one everyone's heard of and scleritis is characterized by severe pain. You know, you'll know the patient will be literally bent double. I've seen two patients bent double with their pain. Tis, conjunctivitis can be difficult to diagnose. Typically, conjunctivitis follows a, a ti contact with sticky eyes and stickiness is quite a prominent symptom. If you look at the cons, you might see follicles, these little bumps like pebbles stones. Um, and whereas Piri the eyes a bit red, often in a patch, um, and it doesn't have that kind of swollen, sticky appearance so much. Um, and it goes on for a bit longer. Sure. Um, I know we've had time there, but I'm going to finish off just with a couple of questions I still have if everyone's happy to do. So, um, I know in primary care sometimes we're limited by the equipment that we have. We don't have a tonometer to hand. But is there any way that we can measure intraocular pressure and how, what sort of things we're looking to suspect, raise interocular pressure? So, yeah, I don't know. II could almost ask you that question. Fire that question straight back at you. We do use handheld eye care tonometers. Uh And I don't know how much they are, but that's what we use in clinic. The nurses check the eye pressures with that and they're mostly reliable at the extremes of pressure. They get a bit inaccurate. But, um, that's what we use. So I guess you could use that. They're really easy to use. Um, and I guess when would you suspect it? Well, um, when you say trauma, II guess, yeah, it depends on the setting. You might want to test eye pressure in all sorts of settings. If you suspect glaucoma, if you suspect a perforating eye injury, you might do pressure to see if it's very low, uh, if someone has a high femur, you might do pressure to see if it's very raised. Um I II. But, um, yeah, it's certainly possible with these handheld tonometers. Um, but, uh, sure. No, absolutely. Um, Sandesh has asked and again, I suspect the question, the answer is complex. But how do you manage total globe rupture in terms of eye trauma? So, um, I guess prep the patient for surgery. So, nil by mouth, um and giving um analgesia an antiemetic as needed um because you don't want them vomiting, um and putting a clear plastic eye shield over the eye, you might not have one of those around. I don't know, I've heard of sputum pots being used, obviously, sterile sputum pots but resting on the orbital bone, not the eye, but the point is on the bone around the eye so that the patient doesn't inadvertently rub their eye and heaven forbid, squeeze a bit more intraocular content out. Um And then get them up to eyes obviously immediately. And then we would, um uh you know, it's normally primary repair that's done. So basically suturing whatever is ruptured, literally just suturing it together to try and maintain the anatomical integrity of the eye. And you know, worry in a way about vision later. Very rarely if it's a massive degree of trauma, primary enucleation needs done, the eyes removed, but every effort is made to try and preserve the eye even if it's clear that, that even if it's suspected there's no visual potential, you know, you want to speak to the patient about something like that first. And so I hope that answers Sandish. Absolutely. I mean, the aesthetic aspect there obviously is important, but I imagine that's way more complex than, than, than it sounds as well. Um Rosette clarified just to quickly bounce back ess surgery being just emergency surgery. So the question more about, is there a link between vision loss and finasteride obviously that um prostate um BPH drug? Yeah. Uh No, not that I know of rosette. I, I'll look that up. I mean, I know um, some of the alpha blockers for BPH can cause a floppy iris which uh makes cataract surgery, um, you know, a bit more difficult, but it wouldn't cause sudden visual loss. I know I could, obviously, I it could be a gap for me. I'll look it up. Yeah. No, absolutely. And I'm gonna, I'm gonna call this the last question from chin. Um, any pitfalls in managing what seems to be a very straightforward conjunctivitis. I'm sure many GP colleagues on the, on the, on the call tonight have maybe even seen a conjunctivitis today. Um, probably, um, or at least within the last week, I'm sure are there any pitfalls, things that we might miss, um, things that are important treatment that's maybe not quite getting to the bottom of it that we should then be seeking more advice on. Yeah, that's a great question. Chin. Absolutely. And that gets, I guess the crux of primary care what could be being missed. Um, I guess all I'd say is that, um, what could be missed are the other causes of red eye. Um, you know, someone has a red eye and especially with the phone, you know, how do you tell or maybe a photo sent the patients taking a photo. It's not a great photo. Um Could you miss acute glaucoma, the fix rated pupil? Could you miss a hypopen? Uh, if you haven't asked if someone's had recent eye surgery or recent eye injection? Um, it, it's all possible. Um So missing one of those other causes of red eyes, I could see uh could happen and, and as an aside, hats off to everyone in primary care, you know, I couldn't do it, see all this undifferentiated stuff, some of which is serious is a frightening prospect. So hats off to your, all your silky skills out there. Um And also if conjunctivitis isn't getting better after two or three weeks, then as I say, we swab for chlamydia, but you have to wonder if it's something else. I'm sure a lot of, a lot of the expert generalist colleagues on the call will really appreciate that. Um, Doctor Williams, I'm going to, I'm going to call it there because, um, I really appreciate the fact that you've stayed on beyond the time to answer some of our, of our attendees questions. Um Thank you so much for this evening. Um I have a lot of takeaway messages, a lot of reminders about tomato soup and seaweed and things that I never quite forgot and that have stayed with me and have been so useful. Um I just want to take one moment to pop a couple of links in the chat for our upcoming events. Um So on the sixth of June at 730 we're going to be talking all things co PD um with Doctor Steve Holmes and that's our next event. And the full details you can find on the app and the event after that, we're going to be talking about cancer and lifestyle medicine. Um Just a little bit later in June and I'd encourage you to check out the app um to find out the details for those events and register now. Um also on the app, as I mentioned at the start, um the new section which we'd really love your feedback on and really love you to have a look at is the patient information leaflet. I am almost certain. Um If we go into the app now and have a look and typed in glaucoma, um we could find an information leaflet explaining the importance to patients of doing their eye drops every day even though they have no symptoms. Um So I'd really encourage you to have a look on there and check that out um with that, um we will close tonight's session and thank Dr Williams again. I'm really, really grateful for your time and the feedback coming in has been great. Um Please do fill out the feedback form which we can then pass on to doctor Williams, um and also get your certificate for attendance and let us know about the topics that you want to hear about and the speakers that you would like to hear from um on the primary care network. Um We look forward to seeing you in June and thank you once again, Doctor Williams um for your time this evening. Pleasure anytime, Tim, good to see you and thanks very much, everyone else too. Great. Thank you, everyone.