OSCE PREP - OCULAR CONDITIONS WITH LAYMENS

ADIES PUPIL

Parasympathetic Denervation

Women > Men

Younger 20-40yrs

idiopathic / Viral infection / Sjorgen / RA

Affected pupil larger in light conditions

Sensitive to weak Pilocarpine 0.125% -affected eye constricts

Management:

• thorough history - any new meds? / associated visual or neurological symptoms / recent trauma?

• Motility, ptosis present?

• Normally no referral.

HORNERS SYNDROME

Can be congenital or Acquired

Any age including birth

Interruption of oculosympathetic innervation along neural pathway from hypothalamus to orbit

Surgery / Carotid Dissection / Stroke / MS / Birth Trauma

Painful Horners = ocular sign of carotid artery dissection

Smaller pupil in dark conditions

Ptosis, Miosis, Anhydrosis , heterochromia

Management:

• Painful = EMERGENCY same day referral if associated with neck pain - neurological emergency - carotid dissection?

• No Pain: Routine Referral to Ophthalmologist/Neurologist will req. MRI of brain, CT or MRI of chest and neck.

ARGYLL ROBERTSON

Bilateral Miosis or no constriction to direct light

Normal constriction to near targets

Neurosyphilis

Management

• Refer to ophthalmologist or neurologist - serological tests for syphilis

ATOPIC KERATOCONJUNCTIVITIS

Chronic inflammation of ocular surface

Sight threatening allergic eye disease

Late teens or early twenties and can persist to 40s-50s

Asthma, Excema, FH of atopic disease

Excema affecting eyelids and periorbital skin

Symptoms:

• itching, burning, watering, photophobia, blurred vision

• mucoidal discharge

• bilateral, can occur year round

Signs:

• Thick crusty lids

• Associated staph bleph

• Conjunctival hyperaemia

• Limbal inflam - trantas dots

• Corneal involvement - erosion, scarring, staining

Management:

• mild - Routine referral GP - for drug prescription - ocular lubricants, ointment @ night, anti-histamines (sodium cromoglicate 2%) , lid hygiene

• Corneal involvement - urgent referral within 1 week to ophthalmologist

Will require management with GP, dermatology, ophtalmology, immunology etc - for topical steroids or drugs or systemic medication and treatment of excema.

ATOPIC KERATOCONJUNCTIVITIS LAYMENS

Hi my name is X and I am the Pre - Reg Optometrist. I am just going to explain to you what I have found today.

From looking at your eyes, this appears to be a type of long-term allergic inflammation affecting the eyelids and the front surface of your eyes. By inflammation, I mean that the eyes are becoming irritated and reacting to an allergy. This can commonly be associated with conditions such as eczema and asthma.

The important thing is that we manage this properly because, if it becomes severe or is left untreated, the inflammation can sometimes cause changes or scarring to the cornea. The cornea is the clear window at the front of your eye that allows light into the eye and is very important for your vision.

For milder cases, we can often control the symptoms with things like antihistamine or anti-allergy eye drops, as well as using cold compresses to help reduce the itching and swelling. For the cold compress, you can take a clean flannel, dampen it with cool water, wring it out and place it in the fridge for a few minutes to make it nice and cool. Then gently place it over your closed eyes for around 5–10 minutes. You can repeat this a few times a day when your eyes feel itchy or irritated. Make sure you use a clean flannel each time. It is also important to avoid rubbing your eyes, as this can make the inflammation worse.

Because your symptoms/signs appear more significant, I would like to refer you to a specialist. They can examine your eyes in more detail, particularly the cornea, and decide whether you need stronger treatment, such as prescription anti-inflammatory medication or other treatment depending on what they find.

The good news is that with the appropriate treatment and monitoring, we can usually control the condition and reduce the risk of complications.”

Do you have any questions? Is there anything you would like me to explain again?

BLEPHARITIS and MGD

Chronic inflammation which can affect eyelid margins, lashes

Acute exacerbations

MGD:

PRESEPTAL AND ORBITAL CELLULITIS

Infection of the periorbital and orbital tissues

Can be minor or life threatening

Common in children <10 yrs

Preseptal: infection of tissues lying anterior to orbital septum - RISK of extension to orbit

Orbital: infection of tissues within the orbit - SEVERE and LIFE THREATENING

Insect bite, recent surgery, sinusitis, trauma, respiratory tract or ear infection

Symptoms:

• fever

• acute swelling, redness and tenderness of lid

• Orbital:

• pain on ocular movement

• blurred vision

• diplopia

• acute swelling of conjunctiva and lids that can be painful

Signs:

• eyelid redness, ptosis, lid oedema , warm tender, fever

• Orbital

• can extend to cheek and forehead

• ptosis

• proptosis

• conj hyperemia and chemosis

• restriction on motility

• reduced va

• impaired colour vision

• RAPD

• fever

• raised IOP

Management:

• Emergency same day referral to ophthalmologist or A&E no intervention

• They will do possible CT scan of orbits and sinus

• children may req admission to hospital for observation

• systemic antibiotics

• blood tests , drainage of orbital abscess

PRESEPTAL / ORBITAL CELLULITIS - LAYMENS

“Hi, my name is X, and I’m the pre-registration optometrist examining your eyes today. Is it okay if I explain what I’ve found and what I recommend we do next?

The swelling and redness around your eye are concerning for an infection of the soft tissues surrounding the eye. This is called cellulitis, which essentially means an infection causing inflammation and swelling of the tissues.

There are two types we can be concerned about. Preseptal cellulitis affects the tissues around the front of the eye, whereas orbital cellulitis is a more serious infection that affects the tissues deeper within the eye socket.

These infections can sometimes happen following things such as a cold or sinus infection, an infection of the eyelid such as a stye, an infection of the tear drainage system, or sometimes following an injury or surgery around the eye.

The reason I’m concerned is that, while preseptal cellulitis is usually less serious, orbital cellulitis can become very serious and can potentially threaten your vision and your general health if the infection spreads.

Because of this, I don't want you to wait for a routine appointment. I would like you to be assessed in hospital today as an emergency by an eye specialist or through A&E.

At the hospital, they will examine your eye in more detail, including checking your vision, eye movements and the tissues around the eye. They may also carry out blood tests and potentially a scan if they are concerned that the infection has spread deeper into the eye socket.

If an infection is confirmed, you will likely be treated with antibiotics. Depending on how severe the infection is, you may need antibiotics through a drip and may need to stay in hospital for monitoring. The eye team may also involve other specialists, such as an ear, nose and throat specialist, particularly if the infection is related to the sinuses.

I appreciate that being referred to hospital today may be worrying, but I’m recommending this because it is important that we treat the infection quickly and make sure it hasn’t spread deeper around the eye.

Do you have any questions for me, or is there anything I’ve explained that you would like me to go over again?”

CHALAZION

CLAPC, GPC