Ophthalmology in Primary Care

Question 1

What causes flashes and floaters?

Answer 1

• Typically due to posterior vitreous detachment.
• PVD happens when the jelly (vitreous) in the back of the eye ages and becomes more liquified
• The more liquefied jelly loses its attachment to the surface of the retina and pulls away either completely (floaters) or partially (flashes and floaters)
• The symptom of floaters represent the perception of the patient to the back surface of the vitreous and other bits of vitreous debris free floating in the posterior segment of the eye
• Flashes represent persistent traction of the vitreous on the retina leading to stimulation of the retina. This is ‘seen’ as flashes.

Question 2

What is the common complication which can develop in a patient who presents with flashes and floaters?

Answer 2

• Patients complaining of flashes and floaters can have a retinal tear which could progress to a retinal detachment.
• Patients who are short-sighted (myopic) are more at risk of developing flashes and floaters and retinal pathology.
• If a patient presents with these symptoms to general practice it is recommended that the patient is seen by an eye care professional for a thorough retinal examination.

Question 3

Describe the presentation of itchy eyes.

Answer 3

• Allergic eye disease is common especially in children.
• Itchiness is prominent.
• Can be difficult to distinguish from viral conjuctivitis due to presenting symptoms:
  
  • Red eye
  • Itch
  • Watery discharge
• History can be suggestive:
  
  • Seasonal
  • Specific exposure
• Certain cliical signs are more prominent in allergic eye disease - follicles and papillae.

Question 4

Describe the development of blepharitis and chalazia?

Answer 4

• Blepharitis - red, swollen and itchy eyelids.
• Chalazia - cyst / stye (painless bump on the eyelid).
• The tear film on the surface of the eye is made up of sugars, water and lipid.
• The lipid comes from meibomian glands of the eye lid.
• If these become blocked then the lashes can appear red and inflamed, the tear film impaired (gritty eye) and meibomian gland cyst can develop (chalazion).
• Lid hygiene treatment: heat, meibomian gland opening cleaning and massage.
• ABx are rarely needed.
• Very occasionally ‘marginal keratitis’ can develop - requires referral to an eye care professional for steroid (+/- ABx) drops.

Question 5

All of these abnormalities are causes of what?

Answer 5

Vision loss

Question 6

What is the main reason why people with headaches present for eye examination?

Answer 6

To rule out papilloedema

Question 7

Describe papilloedema.

Answer 7

• Papilloedema is a swollen optic nerve head due to raised intra-cranial pressure.
• Raised intra-cranial pressure can be due to a range of problems with the brain.
• The two most common are:
  
  • Brain tumour
  • Idiopathic intracranial hypertension

Question 8

Describe the typical headache associated with raised intracranial pressure.

Answer 8

• Worse in the morning or after sleep
• Frontal
• Nausea and vomiting
• Worse on straining or leaning forward
• Pulsatile tinnitus
• Horizontal diplopia worse in the distance or looking to the sides
• Transient visual obscurations
• Sensitive to pain relief

Question 9

Describe the presentation of painful white eye.

Answer 9

• Most of these cases are ‘sub-types’ of the headache cases.
• And somatisation.
• Occasionally optic neuritis can present as a painful eye that is white but would be typically be worse on eye movements.
• VERY rarely posterior scleritis can present like this.
• A group of these patients might also be a ‘red eye’ developing but simply not that ‘red’ yet.