Look into my eyes: Common ocular presentations and how to manage them

Chantelle: Welcome to the first webinar of our new rural health webinar series. We're delighted that so many of you were able to join us this evening. This webinar is: Look into my eyes: Common ocular presentations and how to manage them which will be presented by Roman Serebrianik, the Head of Primary and Specialist Eye Care Services at the Australian College of Optometry. We'd like to start with an acknowledgement of country. RACGP and the Australian College of Optometry would like to acknowledge the traditional owners of the lands on which the event is being broadcast and we pay our respects to their Elders past and present.

RACGP Rural would also like to thank our sponsor Access Telehealth. Access Telehealth provides GPs with free access to bulk billing specialists who conduct patient appointments via video. They manage the entire process via a secure software platform and have a wide range of specialists available. We greatly appreciate their support of this webinar series. Before we start I would just like to quickly go over a few tips on using the webinar platform. You should be able to see a control panel like the expanded image on the left of the screen. If you can only see a few icons like the first image on the far left, please click on the red arrow to open the control panel. The control panel provides you with tools to select your audio options and is also a place to type questions during the webinar. Those who have logged in will be using the mic and speakers option as shown in the image on the screen. However, if there are any internet issues or if you have a slow connection, please switch to the telephone option and use the phone number and access codes to listen to the webinar through your phone. Doing this will reduce the bandwidth being used and provide clearer audio.

We have everyone set to mute to ensure that learning will not be disturbed by background noise, but we encourage you to type in any questions into the question log on the control panel and will endeavour to answer these questions at the end of the webinar. Finally, this webinar has been accredited for two category two QI&CPD points. In order to gain these points you must be present for the duration of the webinar and complete the evaluation activity that will pop up at the conclusion of the webinar. I'll now hand over to our presenter Roman Serebrianik.

Roman: Hi everyone. My name is Roman. I'm delighted to join you today and thank you for tuning in to the webinar. There is a bit of a delay with the transmission so bear with me as I navigate these slides. I currently work at the Australian College of Optometry. We are a non-profit body. We provide about 75,000 consultations to disadvantaged Victorians. We also provide specialist services for other optometrists who refer patients to us on demand. My role at the college includes seeing patients, eye care delivery and I also do a fair bit of teaching. My particular clinical interests include ocular disease management, ocular therapeutics and diagnostic imaging.

I'm particularly delighted to join you because I think optometry and GPs in general practice really work well together, particularly in rural areas, to provide high quality service and I think it's really important because we see those patients with ocular problems presenting either to you or to us in optometry. In optometry we probably we deal with 90% or 95% of all ocular presentations. So I think there's a lot we can do together. Hopefully by the end of today's talk we will learn something together. The reason we talk about eye presentations in the purpose of this session is really because ocular complaints are a common reason for patient attendance at GP practices.

Roman: And as you know ocular presentations can really vary from trivial things that don't require any major intervention to eye threatening or possibly even life threatening, and some of you or most of you probably would have seen a gamut of presentations that you've had to deal with. As you know, diagnosis can be tricky and examinations can be tricky, particularly if you are in a practice that doesn't have a lot of equipment or tools to use. Triaging of ocular problems is very important because trivial things and significant or important things can often look very similar, as we will talk about today. And of course management is important, particularly if you don't have optometry colleagues near you where you have to assume the role of managing these patients. That can be a bit tricky.

Today, we'll talk briefly about the clinical anatomy of the eye but we don't need to go into too much detail. We'll talk about some of the basic tools that are needed to examine eyes and some of these you will have some of those. I can suggest you get or at least refer your patients to other practitioners, who will have them. We will talk about history taking tips because I think - and most of you will probably agree with me - that history is really the most important, or one of the most important things to triage the problem - whether it's something trivial that you can deal with or something that requires referral. We’ll talk about some common ocular symptoms and what they mean, we'll talk about some common ocular signs to look out for, we'll talk about common case scenarios and we'll touch on a few of those just to sort of highlight some common threads in our conditions, and finally I'll give you some further resources and referral options because it's always good to have a plan B in your back pocket if you see patient and you're really not sure what to do with them. So hopefully by the end of this presentation, you'll get some useful knowledge about that.

Roman: And we’ve got quite a number and I'm sure and some of you will have experience with these conditions. If we talk basically about ocular anatomy here, the eye is essentially an optical instrument very much like a camera. The front part of it, probably the front third of the eye is devoted to really getting the optics correct, and then light has to pass to the front of the eye through the cornea, which is the front structure of the eye through the pupil, which is the dark spot in the centre going all the way through the internal ocular structures and hitting the retina at the back of the eye.

So as you know because the light has to pass through a lot of structures, the eye itself has to be very very healthy for the image to reach the back of the eye and work well.

Roman: So, as you can see light going through for the picture on the left, we've got light going all the way through to the back. The important structure for us to think about is probably the cornea, which is the very front part of the eye. Then we've got the lens about a third of the way in and blood has to pass through that transparent body in the middle called the vitreous and then hit the retina, which is the light-sensitive organ at the back of the eye which then sends little impulses off via the optic nerve, which is like a cable going all the way up to the brain. And, just to give you a little anatomical milestone, the optic nerve is about eight centimetres going from the back of the eye and reaching the brain stem. So reaching the brain via the optic chiasm.

So the eye is very closely connected to the brain. So, any significant impact, particularly infections of the eye can rapidly transfer through and we'll talk about some of those today.

And really the way I explain the eye to the patient is very much like a camera with optics at the front and then the light detecting picture making apparatus at the back of the eye. So we'll just jump across to the next slide. On the next slide when it comes up we'll talk about the retina, which is something that some of you will be familiar looking at.

So that's really the external anatomy we’ll talk about first looking at the patient. We don't really need to spend too long on this. Probably the most important thing to remember is the front that the white of the eye that we call the sclera. The sclera joins the transparent cornea at the structure called the limbus which I'll sometimes hear as referring to and then the external part of the other sclera is covered by this transparent membrane like a skin if you like called the conjunctival which is a mucous membrane and probably the site of the most common redeye presentation of the eye, which is conjunctivitis. Now looking through into the back of the eye. This is the picture of the central retina and most of you will probably be familiar with this. The main milestones are the retinol vasculature which is clearly visible.

You've got the top of the optic nerve, and imagine the optic nerve is getting away from us directly into the computer screen and up into the brain. We've got the macula, which is the central part of the retina that will give you your best vision right in the centre. And the thing to remember with the eyes, the eye is really the only part of the body where you can visualise the vasculature of the patient institute. So if you look for patients with chronic vascular conditions - diabetes, for example, if you can see retinopathy, if you can see bleeding at the back of the eye usually the patient will exhibit similar micro vascular changes everywhere else. You just can't see them. So whether it's kidneys, whether it's feet, you know, any other regions where microvasculature is affected, the reason we pay attention to the eye is that you can actually readily visualise it.

So that's actually that's why we talk about it now. This is a very commonly observed picture and everybody's probably most familiar with that. What you want to remember is that's really only the central part of the retina. The retina does extend a lot further than that and that's why we often when you send patients to us, or send patients to ophthalmologist, we dilate the patient's pupil to have a look at the rest of the retina because there’s many many conditions that will affect the peripheral retina first. The picture that we just skipped through and I once again, I apologise about the delay was a picture of a choroidal melanoma, which is probably the most common ocular tumour that can affect the eye and it very much often starts in the periphery.

And, the trouble with that is if you’re just used to looking through a small pupil into the central part of the retina, you will often miss things. Another common condition that you may miss doing that would be something like a retinal detachment which once again is a site threatening condition. Here we go. Site threatening condition, but until it reaches that central retina, you may not see it at all and the patient might not be as aware of it. Now. We'll just try and get back into the order of things. So the first thing we'll sort of talk about is really examining the eye, what do we look at?

And then you can see there's the region of the central retina with the peripheral retina all around. So let's have a bit of a chat about examining the patient's eye.

So if we talk about examining the eye, so what are the things that you actually need if you've got a patient coming in to see you. What information do you want? So in my mind, what you need is you need a good vision chart. Now vision chart is important because you want to get a baseline vision measurement. Now that's important. Not only for yourself to see what the vision is like today. It's also very important for medical legal purposes because you need to know what the patient's vision is like at presentation if you’re going to manage that patient.

Now vision charts come in three meter varieties or 6 meter varieties really depending on the testing distance. The important thing and if you're interested in where to purchase them, or where to obtain them, I can certainly help you. Send me an email. I can certainly direct you to that. The important thing with vision testing is you've got to do monocular testing and you've got to make sure the patient covers the eye fully. We've all been fooled by patients trying to pass, you know for their vision driving test by covering the same eye, but alternating the hands. Another useful tool and probably most of you have but not everyone tends to use is the direct ophthalmoscope, which is really an instrument that you can look into the back of the eye. Now, the direct ophthalmoscope is very much a tool I find used primarily by GPs and optometry students. Optometrists and ophthalmologists don't tend to use direct ophthalmoscopes mainly because you only get to look at a structure with one eye. So we tend to use instruments that allow us to look at the back of the eye with two eyes so we get 3D viewing, so we're looking for swelling and things like that. But certainly for GPs or practitioners who don't really examine eyes all that much, or not exclusively, a direct ophthalmoscope is very handy. Magnification source is good. If you don't have a slit lamp, which we'll talk about in a sec and the reason you need magnification is most ocular structures are very very small.

So, unless you have exceptional vision or want to get really close to a patient, a loop is a really handy. Light sources are good. A white light source is good for general illumination of the eye. A blue light source is very good if you're using it to look for things like corneal abrasions, or if you end up measuring intraocular pressure as well. A slit lamp - which is an instrument you can see on the screen there - very helpful because they allow you to see the patient's eye with a variety of filters and magnifications.

And now I'm aware not many practices will have them unless you co-share your location with an ophthalmologist or an optometrist, but if you don't have one and you've got a patient coming in for a presentation that you’re really not sure of, really useful and ultimately encourage you to refer patients if you can't see what's going on, send them to a practitioner who has a slit lamp that they can have a look at the patient's eye with. You can see a variety of you know, with an ophthalmoscope and things, they come with variety of filters and beams and all those kind of things. Loops are also very helpful. Not necessarily expensive, but certainly indispensable if you're looking at a patient's eyes.

Ishihara tests, which we will mention here is a colour vision test. Once again, I'm not sure if a lot of you will have them but they are very helpful because some ocular conditions can affect the colour perception or the colour saturation of the eye - certainly things that affect the optic nerve - and the trick with colour vision testing with the Ishihara test compared to any of the other ones is you've got to test patient's eyes one eye at a time and you’re actually looking at differences in not just colour perception, but also colour saturation. So a test we’ll often do is called the red desaturation test where you can join if you don't have Ishihara test you can show a patient something of red colour. If you've got red drops or a red pen or something against a plain background and you actually get the patient to cover up the eyes one at a time and tell you whether there's a difference in brightness and often with certain conditions, inflammatory conditions, like optic neuritis, multiple sclerosis thing or a neurological disorder, the patient will say they're red. When they look at the red, they’ll say the right eye is you know a hundred percent red, the left eye is 65-70 and you're looking for that difference to give you a clue whether there's something about the neurological conductivity of that.

Another instrument that's very helpful is a tonometer, which is an instrument to measure the intraocular pressure. Now you will know and I will know there are lots and lots of conditions that can affect the intraocular pressure and can either make the intraocular pressure go very high. Things certainly like glaucoma, which most people most doctors will be familiar with but there are also some conditions where the intraocular pressure goes low.

And once again, it's low compared to the other eye and it's really important that if you're suspecting those, if you've got an ocular presentation, it’s really important to check those. One condition where the intraocular pressure and can go very low is a penetrating eye injury. So you can have a patient coming in with you know, that they've had something in their eye and specifically a grinding injury or something like that where a projectile will go at high velocity into the eye and essentially you get a perforated globe, now a patient will often not have a lot of pain at all, they might have a bit of redness, they might have a bit of watering. But they may have an open wound that is leaking. So the intraocular pressure will fall and there are lots of different instruments to measure the intraocular pressure. One of the newer ones which are really helpful and probably very suitable for a GP setting is a tonometer called an iCare tonometer which you can see here being demonstrated on the child in the picture. Now, that's a tonometer which doesn't require anaesthesia. So usually the trouble is the tonometers as we use touch the eye very gently so you have to anaesthetise the eye to do that. The newer iCare tonometers actually have a probe that flicks out at a very high speed which doesn't cause any symptoms or awareness to the patient, but can measure on children, you know, adults anybody. So very handy and they’re disposable probes. So once again, use them and you throw them out, so maybe helpful particularly if you work in a rural area or you know away from ophthalmology colleagues. A slit lamp we've talked about, and really slit lamps are indispensable for external ocular examinations, you know, red eyes foreign bodies things like that.

Now you can have slit lamps which are table mounted which are typically what I use in my in my work. You can see that picture on the bottom on the left, but you can have portable slit lamps as well and certainly those are useful or we use them when we go out into the community or if we do homeless shelters or aged care facilities and things like that. You can see there's a doctor on the right on the bottom using a portable slit lamp. It takes a little bit of practice. But once again, you're not tethered to a table, so you can have them carried around particularly if you do work away from the office. Some of the newer slit lamps come with a smart phone adapter, which means you can take photographs of what you can see and that's very helpful. Once again, if you work in a setting where you're away from an ophthalmologist or an optometrist nearby, it's very helpful. Now, we'll just swap to the next one.

So, you can see most of the equipment that I or my ophthalmic colleagues will use in our office, you will have access to as well in your in your practice or at least you can have access to if you're motivated enough to seek it.

So let's have a look at the next line where we'll start talking about some of the techniques and history taking once again, we'll just have a look at the next slide - basic diagnostic dyes. Now, these are once again not equipment but really helpful in your practice and some of those you will know for sure. So you've got fluorescein, which I know a lot of GPs use or are familiar with. There's another stain called lissamine green, which probably fewer people here may know. Now, lissamine green is helpful particularly for things like herpetic ocular infections, cornea infections where lissamine green will highlight the edges of that dendritic lesion, really well. But diagnostic dyes are really really important.

Let's talk about pupils while we've got them on the screen. Now, I'm not sure how many of you test pupils - possibly not many at all. I think pupils are really important. So we'll go back to the pupils in a sec. Anaesthetic drops - some of you may have, whether they come in minims, and I'm sure if you do a lot of foreign body removal, I'm sure you will tend to use them a fair bit. Now that with anaesthetic drops they either come in minims or you can have them in bigger bottles. We tend to use bottles.

You guys will probably tend to use minims because they are, you know, if you don't use them frequently enough. The drops that we tend to use a lot that GPs don't are mydriatric drops, which are pupil dilating drops and really helpful particularly if you're, you know, if you're finding viewing the ocular fundus difficult with your direct ophthalmoscopes by all means dilate the patient's pupil once, you know that's safe enough to do so because you'll get a much better shot at looking at it too. So, you know, my the ophthalmic colleagues and I, we get very used to you know, looking through one to two millimeter pupils with our instruments, which I understand it can be a real challenge, particularly if you don't do that very often. Another drop that we tend to use a lot of would be saline for ocular irrigation, whether it's contact lenses that get stuck in the eye, adhere to the conjunctival or whether its foreign bodies and things like that.

Some of you will may use saline, some of you may not. But it's certainly a very helpful thing. So, you can see if as you start gathering your tools between having an instrument that you can look at the front of the eye like a portable slit lamp or a loop and having an instrument to look at the back of the eye and then adding some diagnostic stains, you should start getting a really good tool kit for looking at the eye.

Now we'll have a look at the next slide when that rolls up and we will talk about pupils now. I don't know how many GPs routinely look at pupils but I find testing pupil reactions is really important, particularly for patients who present with eye problems of vision changes and things like that.

When we test pupils - and this might be a little bit too slow for us to go into a real life - but there are three types of pupil reactions that we look at. We look at direct response, which is when you shine the torch into somebody's eye does their pupil constrict? And, if the answer to that is no then the patient is a really significant deviant we call it. Deviant where it goes from the eye to the brain. So whether they have a optic neuritis or whether they have a torn or significantly damaged optic nerve, you know, or end-stage glaucoma or something, if the pupil doesn't constrict that means you're not getting the information about the light to the patients brain. Central response is the response that you get in the opposite eye. So, if I shine a light into your right eye, I expect the right pupil to constrict and I also expect your left pupil to constrict. If you're right pupil constricts, but your left one doesn't, then I know there's a problem between the brain telling your other eye what we call the efferent pathway. So, pupil reactions are really useful in in just triaging where the problem lies. The near response essentially is a test where if I get the patient to look at a near object, I would expect their pupils to constrict as the eyes come together and there's some you know, very specific conditions where you get this light need association, but direct and the consensual are probably the two responses we would look at the most.

The Perla acronym for the pupils is quite helpful. Pupils that are equal round and reactive to light and accommodation, so pupil equal round reactive to light and accommodation, which is that near response. Pupils are really useful for neurological problems, angle closure glaucoma where a pupil gets stuck and does not constrict, and things like uveitis where you'll which is the inflammation inside the eye. You'll see that pupils are not being round, so the pupils being sort of an unusual shape, keyhole shaped or you know little regions are stuck to the eye. A swinging flashlight test is worth having a look at after this and that's how we test for this affront people reading if you're looking for an unequal constriction or unequal dilation. So, it’s definitely well worth using looking at how to do pupil reactions for patients.

And once again, I don't know how many GPs do pupils routinely, essentially you've got a pen torch or a direct ophthalmoscope, which most of you will have at some point or a strong, you know strong torch of some kind, which will do nicely. The torch that you want is something that gives you a fairly confined beam of light, you know, you don't want a dolphin torch, you know, that illuminates the patient's head completely. You want something where you can control the beam.

Yes, so pupils (clinical examples). So, as you can see here you’ve got uveitis – that’s inflammatory reaction of the eyes. Some of the segments of the eyes become very sticky and attached to the lens behind. So, as you can see if you dilate the pupil or even if you look at the pupil with direct light you can see these areas of attachment where you can see at about six o'clock and nine o'clock and we call this synechiae and you definitely want to break those before too long. The picture in the middle is this thing called the relative afferent pupillary defect where we shine a light into one eye and then as soon as we swing the light to the opposite eye that pupil still dilates, and that just tells us that there’s a bit of optic atrophy. So the optic nerve is not working as well. Finally, on the right you've got this acute angle closure glaucoma with pupil block and the pupil is stuck in this middle position. And, because the pupil gets stuck in the middle, it sticks to the lens at about that 360-degree thing.

Which then makes the iris behind the lens bow forward and so the aqueous humor cannot drain around the eyes. So it cannot drain into the drainage channel. So pupils are kind of a good little snapshot of looking at something to see whether you know what sort of problem are you dealing with. It's a very useful thing.

So we'll talk about history taking because that's really important. I’d say the main thing for GPs to know is what is an ocular emergency? How do you recognise something that really is important? So in my mind, an ocular emergency is something that presents with vision loss, something that presents with potential loss of function where you think if I don't deal with it now the patient may suffer an irreparable loss, whether it's loss of vision, loss of ocular motility or something that you know, they will not regain back and that's the same with condition that potential for permanent structural damage - something that unless you address now will not will not go away and then obviously things with potential loss of life. There's thankfully not too many conditions that can give you loss of life but things like giant cell arteritis or orbital cellulitis or something like that which you know, you see me you think to yourself I might be the first practitioner to see it. The ocular presentation is the first manifestation of whatever the condition is, and I really don't want to mess this up.

So, if we talk about history taking and if we talk about some of the symptoms the patients might present with - change in vision is important. Often our patients will come in and say ‘Oh, you know, I can't see.’ This is not a helpful thing because you don't know whether they've actually lost it, or where they’ve lost the vision, or whether it's just blurred vision and it's really important to separate those at the outset. If the patient says ‘I've lost vision’, what you want to know is, have they lost vision in one eye or both eyes, of course, but then is it lost everywhere or was it a particular area of their vision, because if they've lost it in in a particular space (superiorly, inferiorly, temporal or whatever), that might be something like a retinal haemorrhage or something that is not a neurological or an optic nerve issue, but maybe something inside the eye. You also want to know if the patient says ‘My vision has changed,’ you want to know, has it changed suddenly like somebody's turned off the light because that could mean something like a vascular problem like a retinal artery occlusion or a neurological problem versus something that's come on gradually. And, gradual things, you know you want to know is it in a week, in a month, in 12 months where there is a refractive error type thing like they just need their glasses updated, which is the easiest example to deal with or maybe they've got some early cataract and if you do suspect they've got an early cataract coming on, you want to make sure that's consistent with their age. If somebody's coming in with a gradual reduction in vision and their 25, you wouldn't necessarily suspect a cataract as compared to somebody who's 85 or 90 or 75 or 65 even. Somebody with a cataract is usually an age related condition. Finally, the things you want to watch out for as well with change in vision, is a transient change where it goes blurry for a little while. How long? 5 minutes, 10 minutes, half an hour, whatever it is and then comes back which is often sort of a vascular problem or a giant cell arteritis type condition, or is it a permanent change in vision which could be a vascular occlusion where they've lost blood supply to the eye or a neurological problem or something but you want to know does it come and go and how long does it last for or whether it stays like that and it's permanent. So that often will give you a bit of a clue as well on what you're dealing with. You also want to know whether that change in vision is mild versus severe and then because that will tell you how urgent or often it will give you an idea. And, you also want to know if the changes were monocular – so, only affecting the eyes, only affecting one eye or whether it's binocular. My advice would be, if you're dealing with the patient in your practice, in the GP practice who says to you, ‘My vision has changed.’ My recommendation is to refer that patient out.

So, you don't want to deal with something like this because most things that are easy don't cause change in vision, you know things that are light or easy to deal with. The next common. The next common presentation you get is pain. And once again, if a patient says my eyes hurt that's not helpful unless you can sort of get a little bit more information about the symptoms. So, is it actual pain or is it only discomfort? You know, if it's actual pain, can you tell us the scale of the pain from 1 to 10 or from you know a little bit to very severe or something like that because you'd want to delve deep into it and some of these you probably know as well. Is the pain constant or is it intermittent? If the pain is constant, that’s one thing but if it's intermittent and it comes and goes can the patient help inform you about when it hurts, you know, is it is it worse on blinking? Okay, is it a foreign body? But perhaps maybe tucked underneath the upper eyelid. Are they a contact lens wearer? Did you definitely take your contact lenses out or have you lost your contact lens? Oh now that you mention it, I haven't been able to find it.

Maybe it's something where the pain is worse than eye movement. There are some conditions like optic neuritis for example, or scleritis where the pain is worse than eye movements. Just describing the situation in which the symptoms are worse will often be helpful. If a patient can describe the pain to you that's really helpful. You know, is it boring like a deep drilling pain that could be a typical thing of psoriasis? Is it a sharp cutting pain? Maybe that's a corneal abrasion. Maybe is it a burning pain? Maybe it's a bit of dryness, or do they have sort of dull surrounding pain, which is sort of probably the most common thing - sinusitis. So the more adjectives you can build around the symptom, that's really helpful. And, is the pain diffuse or local is also really important. So, as you get more information out of it out of the patient, you will start to get a little bit more information and you'll start to build up a little bit of a case.

Now, double vision is once again very common. We often get patients referred from GPs for double vision, which is fine with what we are here for. The number one easiest test I use to check if a patient comes in with double vision is to get them to cover one eye and tell me if they're still seeing double. So if a patient covers one eye and says ‘Oh no, but if I look through my right eye on my left eye only I'm still seeing double,’ that's not true double vision. That's most likely to be blur, you know, because double vision by definition means two eyes, both eyes are not pointing at the same direction. One is up, one is down, one is left one is right, but they're not pointing together. If a patient is diplopia with double vision out of one eye that's usually a quality of sight. So, you know, they’ve either got a cataract which is the number one most common condition or whether they’ve got corneal scar that has developed or something like that.

But, binocular double vision is a significant symptom, particularly if it's newly onset, you know, then you really ask about if it’s a muscle problem? Do you have a head injury? Is that a cranial nerve problem? Is that a vascular problem? Are they a diabetic with a micro palsy or something, or is there an orbital or inoculum mass brain stem surrounding it, you know the optic nerve or the cranial nerve number three that goes to the eye number six or something like that. Diplopia, once again, you want to know if it’s constant or is it intermittent. And, also the second probably important thing you want to know - is the double vision horizontal as in two things are together side by side, or is it vertical one on top of the other because that once again that tells you or us which ocular muscles might be involved.

The last thing you want to know with diplopia is if it is competent, which means in all directions of gaze, up, down, left, right, up in the corner or if it is incompetent and only happens when I look to the left and happens when I look to the right. That tells us whether all muscles are involved or if one muscle is involved, or if all cranial nerves are involved, which is more unusual versus the cranial nerves that go to particular ocular muscles. We’ll run through the last couple of things with history taking. Another common symptom is flashing lights, which I'm sure you've seen. The important thing with flashing lights is you want to know how fast the lights are and how long do they last? A flashing light in the corner of their eye that lasts less than a second or so is usually due to retinal traction, with something pulling on the retina.

The most common condition that causes that would be a retinal detachment out of the most common in sort of the rare ocular problems that we talked about. Retinol detachments are 1 in 10,000. Flashing lights are relatively common in some patients because as we get older that vitreous body, that gel that sits in front of the retina, gets a little bit loose and gets a bit more watery and sort of starts to wobble a little bit more but it's really important if you're getting patients with new onset flashing lights, you have to exclude a retinal detachment and to do that you have to dilate the patient's eye unless you're going to dilate them and really spend the time looking around in many directions with a direct ophthalmoscope or send them either to an optometrist or an ophthalmologist nearby for them to have a look just to exclude that from a both a patient outcome scenario and also from a medical legal scenario.

Now, if a flashing light lasts longer than five minutes the most common explanation is probably a migraine and people can have ocular migraines, they can have atypical migraines where they don’t get the nausea and sort of you know Kaleidoscope things and vision changes. Sometimes they just have that as a prodromal thing. Floaters or dark shadows. Once again, most of them are benign called vitreous humour syneresis. We talked about this sort of liquification of vitreous or retinal detachment which is urgent because you only really have about three to four weeks to repair that before the patient loses vision significantly. They do need a retinal dilated fundus examination to see it and really I wouldn't expect a GP to really do that because you don't have the time and you don't have the equipment. So I would suggest sending flashing lights (new-onset flashing lights and new-onset floaters) off to the GP and always with patients with ocular problems you look for associated factors because they will make certain things more likely. So, is the patient a contact lens wearer? In this case your corneal infections and abrasions are more likely. Has the patient had trauma? If they had trauma, what kind of trauma did they have? Is it penetrating? You know, do they work in a construction site? Do they grind? Do they use a metal grinder? Do they work in the garden, have they had a scratch that has come into contact with plant material because they're more likely again for corneal infection particularly fungal infections. Have they had blunt trauma which can cause retinal detachments and things like a little bleeding at the back of the eye? Does the patient have photophobia, which is sort of a version to light which usually happens when the iris of the eye gets a bit inflamed. Do they have a fixed pupil and should you worry about angle closure glaucoma and obviously does the patient have discharge? Discharge is a lecture in itself, but if you have a patient with discharge you want to know what kind of discharge do they have? Is it purulent? Is it pussy, which is usually a bacterial infection? Is it mucusy? Is it more likely to be allergic? Is the discharge watery, which is often either a sort of allergic reaction which I think often you'll get a bit of an itch. Sometimes you can have sort of toxic reactions where the eye gets so unhappy that you sort of get this tear secretion running through, you know hyper secreting the tears. So there's lots of things when you're examining, there are lots of things to look at including recent medical issues. And we always look at whether they are more likely to have viral infections particularly if they've had you know, if they've got swollen nodes, an ear infection, a throat infection, things like that. So we'll talk a little bit about the clinical scenarios. And, once again, I do apologise about the speed of the presentation because it is sort of slowing us down.

So the most common presentation that you guys will deal with that we often deal with as well is a red eye and as you know with the red eye, correct diagnosis is really crucial. And when we think about red eye you might think to yourself - well, how hard can this be? It's just red eye. Now, unfortunately there are lots and lots and lots of things that can cause a red eye and you know that if you talk to an optometrist or ophthalmologist, that we spend semesters at University looking at red eyes and you'll be happy to know we won't worry about all of those but you can see there's lots and lots and lots of different possibilities that we always work through now and I’ll make a reference to this little thing here. This is a booklet that was produced by the Sydney Eye Hospital and it is well worth getting. I'll give you a link at the end of the talk. It's a very handy thing to have because it actually steps you through some of these presentations and some of the differential diagnosis for the red eye. This is a short list as well but they go from bacterial infections to dry eye to angle closure glaucoma to uveitis and other inflammatory conditions to lots and lots and lots of things.

Oops, so the first thing we just skipped through was a bacterial conjunctivitis, which is probably the most common thing that you will see which is that sort of red eye with lots and lots of sort of ocular puss and very easy to deal with. The second case study is probably the one that we should spend a bit of time on. Now with bacterial conjunctivitis, just an important thing to think about, there has been a little bit of a debate about whether we treat it with broad-spectrum antibiotics like chloramphenicol or something. Or, do we just leave it alone and just let it run its course and there was a lovely study done at the Lancet which sort of said, you know treating it makes no difference essentially. So, often the most important thing with bacterial conjunctivitis is really to limit the spread as you know. If it’s a child or the most common presentation is the child of brings it home from childcare or from school and the trick is you've got to make sure that your child doesn't share bedding doesn't share towels and things with the rest of the family, because they'll pass it right on, it is fairly highly contagious. Treating it often, you know, just washing the eye out is just as effective as broad-spectrum antibiotics. This case study is well worth having a look at. So, we've got a patient - a 25 year old female – who comes in with a red-eye, about 48 hours in duration with some discharge coming out of the eye. Now, based on she's a contact lens wearer. She wears them seven days a week and especially wears them overnight. Now the patient comes in and she tells you she’s got mild to moderate pain, and remember pain is not good like we talked about before soon as a patient tells you pain you always worry. They've got photophobia. So they’ve got this aversion to light and they've got watering. So the question we get is, what's your diagnosis? And what's your management? Some of you will already know. Now just a quick word about this picture on the left. Now keep in mind. You've got a picture here often makes it easy because it's magnified 20 times and you've got fluorescein dye that's added to highlight the lesion.

What you might not appreciate looking even direct this picture, there's actually a fair bit of a divot in that corner. I know if you can actually visualise but that cornea sort of half melted through and that fluorescein dye pooling in the eyes is actually a lot lower than the surface, so you’ve got a cornea that's melting. Another thing to notice is that the bottom of that cornea at six o'clock you get this collection of puss that’s inside the eye. We call that a hypopyon. Now, here you see you can sort of see it, but imagine looking at this patient across your desk or in your consulting room where you don't have a slit lamp. You don't might not be able to spot it very clearly. So question is then what's your diagnosis? And what's your management?

Some of you will know that directly, but this is a much more sinister condition than a bacterial conjunctivitis. This is microbial keratitis. Bacterial keratitis is a corneal ulcer and the reason this is important is because it's an ocular emergency because it's a threat to vision in the threat to the eye within 24 to 72 hours. There are some microorganisms particularly those associated with contact lens wear which can chomp through a cornea, which is only about half a millimeter thick within 24 hours and the eye can perforate. So, it's really important if you have a patient with a really angry eye with pain either have a good look at it yourself, or my recommendation would be direct send them across to an ophthalmic colleague, whether it's an optometrist and ophthalmologist just to make sure that you don't miss those because you need to examine the area with high magnification, often with diagnostic dyes. And, these patients require potent antibiotics typically fluoroquinolones typically hourly, certainly at the start. Sometimes I might get maybe 15 minutes or so for things like that. They might get corneal scrapes, corneal cultures. And, the other thing is if you are going to manage these patients yourself, if you're in a very rural area, you might be it. You might be the only one available. The thing is you have to you have to monitor these patients closely for improvement. With these patients you can’t tell them to come back and see you in a week or two. You have to see them the next day or the day after and say if it gets worse you must call me. So when I see these patients I will often give them my number and say call me if it gets worse. These are my treatment recommendations. So the thing to kind of remember is not all red eyes are bacterial conjunctivitis, some of these look very similar, but they have very distinct etiologies - from abrasions to foreign bodies to viral infections to angle closure glaucoma and they're all really difficult to examine particularly if you can examine the eye in as much magnification.

The thing is not to forget associated structures, don't forget eyelids. Flip them to have a look for foreign bodies. Pull the lower lid down to look for things like follicles. Follicles are little rice shaped structures in the conjunctival of the eyelid. Very common that you can see the bottom of the right there. Very common. They are common particularly for conjunctivitis in young people, particularly young men. Let's be honest. It's a chlamydial infection. So, young men who are dealing with grumbling conjunctivitis for long periods of time, two, three, four weeks, sometimes longer. They come back and say, you know, I've tried the drops over the, you know, tried to climb finical drop over the counter and it’s not shifting. Think to yourself, you know, most conjunctivitis bacterial things will clear on their own. You've got viral infections on the left. There's your typical herpes simplex infection, not all of them are going to look that lovely. So think about itch as a symptom because that's usually allergy, think about the associated burning for dry eyes, think about types of discharge - remember mucusy discharge, most likely allergy, watery discharge most likely a little bit of dryness, some maybe a little bit of a toxic reaction. Ask about trauma and some of you have posted a question about trauma as well. Trauma is really important, particularly high-velocity trauma. So, blunt trauma you worry about bleeding retinal detachment - things that transfer forced to the back of the eyes. You’ve always got to dilate the pupils and have a look. High-velocity trauma is what I always ask the patient about grinding, lawn-mowing things like that because things that hit the eye at very high speed. Remember the cornea is only, it's tough, but it's only half a millimeter thick so things will go through the cornea, particularly metal projectiles or little stones can penetrate the corners. You always worry about those and you've always got to check if you suspect that. You've always got to put fluorescein in the eye and check that the eye is not perforated. You do this test called the seidel test.

We'll have a quick look at this case study number three. So you got a 75 year old older patient, remember unlike the previous time, we've got bit of redness and you can see once again the conjunctival around the eyes quite inflamed. Patient complained, not of pain so much, more headache and nausea and mild blurred vision. And, you know, the patient has a bit of a cataract because they're 75 and you can see the pupil reactions are little bit yellowing. You can see. That's why I often just have a quick look at the patient's eye and if it comes up really yellow, you know, yellowish reflection, you would look at that. Now, I'm just waiting for the next slide to give us a little bit more of a view about this patient. Some of you might, if you're playing at home, you can try and hazard a guess at what's going on with this patient.

We mentioned the condition before, look at the pupil. You would shine a light into that pupil and that pupil is not shifting. We're getting a little bit of cloudy cornea mid dilated fixed pupil and hopefully some of you might have guessed what's going on with this patient, an older patient with a red-eye, monocular red-eye so one side is red. Very occasionally this sort of condition presents us bilateral redness, but usually it's monocular right now.

I'll just wait for the slide to tumble over at some point. Hopefully some of you would have guessed this already this condition.

Here we go. So it's angle closure glaucoma, surprisingly common. Now, the number one thing this gets confused for as you might think about is to get confused for a stomach problem because often these patients will come in with nausea and vomiting and they may even present to a emergency department of a hospital and they get put in as you know, food poisoning of gastric starvation until somebody notices - hang on the eyes are a bit red or you know, the cornea is getting a bit cloudy and the cornea gets cloudy when the pressure goes very high. So, for most people intraocular pressure is about 10 to 20 millimetres of mercury. In angle closure glaucoma, the pressure go can go up to 45, 55, 60 and even higher than that and with that sort of pressure the optic nerve, which is the weakest part of the of the eye at the back, really starts to bow backwards because the pressure is so high and all the little nerves passing out of the eye get squished.

Essentially atrophy and you can cause you know permanent vision loss in about 24 to 48 hours. So once again, it's why it's really important with red eyes, particularly in older patients, monocular red eyes in older patients, it’s really important not to hang on to them, particularly if you cannot yourself measure the pressure inside the eye. Most of you won't be able to unless you've got a tonometer or a colleague who has access to one. Finally, another red eye which once again looks fairly similar to the others, once again pupils a little bit sort of mid dilated, but you can see pupils not quite round.

They have a patient with a history of rheumatoid arthritis or similar autoimmune disorders are more likely with this condition. But we've got photophobia so version for light distorted pupils cells and flare are sort of little leaking blood materials within the anterior chamber, which is the space between the cornea and the eyes. Now you will not see that yourself unless you've got a slit lamp but you've got limbal redness which is redness around that where the cornea joins the conjunctival so the cornea joins is clear pardon me and some of you may know what this condition is already and if this slide turns over we'll all know.

So this is a uveitic type condition where you've got an active inflammation going on. There's a picture of a cells in flare under that's probably about 40 times magnification. So it's acute anterior uveitis. Pardon me. Acute anterior uveitis - really important that you have to treat these patients with topical corticosteroids. And, then if you are going to treat those yourself rather than refer them out, just make sure that you're monitoring their intraocular pressure because about 20% of patients they will have an associated intraocular pressure rise as so you can have the sort of steroid-induced glaucoma. So you don't want to keep your patients on topical steroids for too long, even weak steroids in some susceptible patients can cause an intraocular pressure rise if there is steroid responder. So something like that were you suspect it might be uveitis, you're better off actually sending them off to be managed by us.

Another sort of thing we'll talk about is headache. Once again headache is multifactorial. We can once again spend a whole presentation talking about headaches. The things to watch out for with headaches in eyes is beware of vision loss, particularly transient vision loss. We call that amaurosis fugax. Now, once again, it's not that uncommon for us to see patients with as I’m sure you’ll know that this is giant cell arteritis. And now this is a both a vision eye threatening condition but also a life threatening condition because patients can develop these occlusive lesions that will essentially can block up either ophthalmic artery where they can lose their vision or even basilar artery or sort of our other blood vessels that supply the brain as well. And as you know, these are medical emergencies. Scalp tenderness and temple tenderness also called “Ropy” pulseless temporal arteries - you know how to examine those with blood tests. You will know the things that will often give it away if we’ve got a patient with a bit of a history that maybe they'd get they often get these swollen optic nerves with little splinter haemorrhages around the edges. And once again, if you've got a patient with a headache, particularly in older type patients, always have a think about that at the back of your mind and if you've got the ophthalmoscope there, have a bit of a look if you've got an optometrist or an ophthalmologist nearby, just send them. Just send the patient along just to rule out, unlikely but possible, you know, so the things you have to think about is whenever you're seeing a patient, am I dealing with an eye emergency? Is this a problem with a sudden onset? Now, with a sudden an onset you always worry about them than more than a gradual onset. Are the symptoms severe? So, remember most mild things will produce mild symptoms. More severe things - the more severe the symptoms, the more you should think about referring them on to an ophthalmic colleague. Is the patient experiencing ocular pain? Remember, talking about mild things really shouldn’t cause pain. Pain should send alarm bells to you that there's something serious going on. You know, conjunctivitis does not cause pain. You know pain is a significant condition. Is the patient having a change or loss of vision? Remember anytime you think you see change or loss of vision, it's not going to be a mild condition, definitely send them off to an ophthalmic colleague. If the patient is experiencing aversion to light particularly new onset photophobic response that is often associated with uveitis or something significant going on and if the patient seeing flashing lights, always think about retinal detachment as a possibility - not common, but possible, you know and always consider referral for those. So, then the sort of question really is should I refer eye problems to an optometrist or an ophthalmologist near you? So referral triggers that I often talk to GPs that I'm fortunate enough to work near to. Refer if you can't determine the etiology of why the patient is complaining. If you really can't, if you're really not sure and you’re concerned by all means send them off. So refer a patient that has symptoms of pain, photophobia and significant things. Pardon me, alright guys now it's trying to run away from us.

And, we'll go back to that. So, refer if a patient has pain or symptoms that you know, you're not comfortable with managing. Refer if the patient’s condition is getting worse. So, by the time they see you they said, you know, I saw I had this problem it started a little while ago. It's feeling like it’s getting worse. If it's getting worse, by all means send them along to us and we can help. And, certainly refer if it's a unilateral eye problem. If a patient comes in with a unilateral red eye, and I know a lot of you have this as a mnemonic, you know, your natural red eye. It's uveitis or unilateral red eye its angle closure. It's often more complex than that. But if you have a patient with a unilateral eye problem, it’s less likely to be a trivial problem.

You know, so, I'm an optometrist so how can I as an optometrist, or my colleagues help you as well? We’re often practicing in the locations close to you guys, you know, whether its shopping centres or whether it's clinics like with like the Australian College of Optometry where I work in Melbourne. We can do a lot of the grunt work for you, you know, we can do ocular health assessment because we have the training, we have the equipment and we can communicate directly with you. We can do anterior segments, posterior segments, intraocular pressure and we can do imaging, and we can do photography. We can do these high whizz ocular coherence tomography scans, which are essentially a real time ocular tissue scan. It scans to a thousandth of a millimeter. We can prescribe therapeutic agents to deal with a range of conditions. We can co-manage complex eye diseases. We can triage those patients on your behalf with ophthalmology. If we can get them in we can triage the problem and get the patient fast tracked if they need to be fast tracked and we can certainly co-manage things with you. There's no formal referrals required. We've got the equipment. We've got the training. We're happy to share that knowledge with you. If you've got an optometrist near you with equipment. If you've got a bit of time, if you want to learn how to use things and yeah by all means pop in and make contact. We’re always thrilled to hear from and to talk to GPs and I certainly know where I work in Carlton we have a network of GPs that we share knowledge with quite regularly. Give us a call. If you don't, particularly, if you work in a location which doesn't have ophthalmology nearby, definitely give an optometrist to call. If there's somebody, I would definitely encourage you to to make contact with and I say, ‘Hey if I get tricky eye patients, can I call you? Most things we can talk through over the phone, well at least give you a, you know, we can nut out the problem together with you to work out whether the patient does require a referral. Can they be managed locally? Can you manage them? Can we manage them? What's the time frame and things like that?

Having said that there are also some useful online resources. The Sydney Eye Hospital Eye Emergency Manual that I mentioned before, I would strongly encourage you to get it. It's a free download and it's available. It is often the eye medicine manual referenced on a lot of the other public hospitals, who have adopted it and it really goes through some sort of step by step diagnosis guide, step by step kind of procedural things to help GPs and other primary care practitioners. It’s very helpful definitely to even print out a copy of have it on your desk. The Royal Australian New Zealand College of Ophthalmologists (RANZCO) has a really good website as well with, you know, with sort of some how-to guides for health practitioners and some information to give patients as well. And, also the other thing is if you're in an area where you're not sure where your nearest optometrist is, you can find us on the optometry website. It has a find an optometrist feature where you can search geographically or by name. Geographic this probably helpful. So, the resources are there and hopefully between all of us we can really serve our patients better. The eye is one of those funny things where it’s tricky but it's very rewarding to solve problems for patients. But unfortunately there aren't a lot of sort of easily things. Once again, I would definitely download this. If you take one thing away from this talk, it is to download that. It will give you a lot of useful information and if you have trouble downloading and you can't find it, let me know. If you're particularly dedicated, there are some useful book resources and these are all picture heavy which is very helpful because you know, you will teach you either conditions or what they look like or how to do certain things. You know, one of the books that I put up there is called the Atlas of Primary Eye Care Procedures, which will show you how to flush the tear duct if you're particularly keen, how to instill things, how to do suturing how to pad the eye and patch the eye and things like that, but otherwise by all means, please utilise us. I'm a bit loathe to go back because we might lose the page given our recent speed, but I just want to thank you. Thank you again for your attention. If you've got any information, and I'm saying we might not have a lot of time for questions, but I'm happy to answer some directly. My email is at at the end of the talk and by all means please get in touch and I can certainly answer questions. I can direct you to your local, you know practitioners or find you a contact to talk to. And once again, thank you very much for your attention. Thank you.

Chantelle: Thank you Roman and apologies for the delay with the PowerPoint this evening. I think we had a high number of attendees, and it was leading to a few delays. But thank you for persevering for with us this evening. Just a reminder to complete the evaluation form that will pop up in a new window in just a moment once the webinar session closes. This will take no more than a minute to complete and is related to the QI and CPD points. Certificates of attendance will also be made available for those who completed by their QI&CPD statement within the next few days, but for any RACGP members who might want a certificate of attendance, please email rural@racgp.org.au. So, thank you and good night.