Getting ‘Worked Up’ Ophthalmology Technical Essentials
description
Transcript of Getting ‘Worked Up’ Ophthalmology Technical Essentials
PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE
Getting ‘Worked Up’Ophthalmology Technical
Essentials
Britta Hansen, OD, FAAOMarch 22, 2014
Berkeley Optometry Grew up in Minnesota Residency at San Francisco VA Work at Northwest Eye Surgeons
Who am I?
“Triage”
Components of technical exam•History/chief concern(s)•Phone/walk-in triage•Vision, refraction•Confrontation visual fields•Extraocular motility•Pupillary reaction•Intraocular pressure, angles•Additional testing
Patient examples
Outline
Base questions upon:•What you expect as an answer•What diagnoses you’re considering/past experience•What they’ve already told you
Chief concern/Phone Triage
VS.
Let the patient [briefly] tell you what’s wrong
Ask new questions that make sense:•Pain = what scale?•Redness, blurry = how long? What scale?•Headache = tried to alleviate?•Any eye drops = side effects?•Any new medications = side effects?•Injury = flashing lights, floaters,
bruising?
Where to start?
Some patients will overstate their symptoms
Others will downplay their symptoms Knowing the right questions, trusting your instincts and continuously re-visiting your process for triage regularly
There is an art to this…
See ASAP See Next AvailableExtreme pain BlurrinessExtreme, new blurriness Ache, strainExtreme headache Chronic rednessExtreme vision loss Symptoms that follow a more
“chronic” patternNew double visionNew moderate to severe rednessVery recent injury to eye or orbitAnything that follows an “acute” pattern*Consider your office’s “specialty,” may want to have the patient scheduled with a more urgent center based on some symptoms
How to schedule?
Subjective versus Objective testingSubjective History/Chief Concern
Objective Fields Motility Pupils IOP
• Vision?• Refraction?
Patient medical history Family medical history Patient ocular history Family ocular history
•Which diseases are inherited?♦Macular degeneration♦Glaucoma♦Retinal detachment♦Strabismus (eye turns)♦Low vision disorders: ie Retinitis
pigmentosa, ocular albinism
History
What questions help?
HPI = History of Present Illness
•Location•Severity•Quality•Duration•Timing•Context•Modifying factors
Primary eye care setting•More weight on refraction, contact lens fittings•Less weight (but still important) on chair skills
Tertiary care setting•More weight on chair skills to help with
diagnosis
There is overlap between the settings, knowing what to do in each instance will help to have a smooth work-up
Know Your Patient Base
Components of technical exam•History/chief concern(s)•Vision, refraction•Confrontation visual fields•Extraocular motility•Pupillary reaction•Intraocular pressure, angles
Triaging patient examples
Outline
“Chair Skills”
The Eyes are an extensionof the Brain!
Visual fields Finger Counting: all or none Transilluminator fields: all or none Automated perimetry: qualify visual field defect
•Humphrey•Matrix•FDT
Abnormal fields:•Glaucoma, other optic nerve problems•Retinal detachments•Vein and artery occlusions•Stroke, tumor
Tropia: one eye turns in (eso) or out (exo)
Main question: do you see double?
Extraocular motility
“Double Vision:” poor blood flow to muscles around the eye, muscle trapped from free movement
Extraocular Muscles
Patients with SYMPTOMATIC double vision will tell you. PUPILS can be very important in this case.
Extraocular Muscles
Extraocular movements
Poorly controlled diabetes Poorly controlled blood pressure Graves Disease Congenital Entrapment from an injury Anomalies of the nerves Compression to the nerves or the muscles
Reasons for rare eye movements
Pupillary Action
Equal size/shape Equal reaction to light Similar movement when the light is in the other eye
Relatively the same movement when swinging back and forth
What to look for
Anisocoria- difference between pupil size
Horner’s- miotic (small) pupil Adie’s- acute dilated pupil Relative Afferent Pupillary Defect
•If present, it can be VERY important as a component of the doctor’s exam
•This is a RELATIVE difference between the two eyes and their brain input
Pupillary testing
Asymmetric glaucoma Blood loss to the OPTIC NERVE in one eye Retinal detachment in one eye Blood loss to the RETINA in one eye Compression on the optic nerve in one eye
NOT: Cataract NOT: Amblyopia NOT: Macular Degeneration or Scar
Things that cause an RAPD
http://www.richmondeye.com/wp-content/uploads/2014/01/d097550bb4b088bb4853b2992c86d90a.htm
Pupillary Demonstration
One pupil doesn’t work because of an iris injury
A patient has a new concern in the “good eye” where the “bad eye” already has a relative pupil problem
Complicated Pupils
Monocular? Binocular? Without correction? With Correction? Distance? Intermediate? Near? Pinhole?
Vision
Reduced vision•Glasses wrong/outdated•Cataract•Macular disease (edema, epiretinal
membrane, macular degeneration)•Sudden loss of vision (vascular disorder,
retinal detachment)
Vision
Change from glasses? Best “corrected” visual acuity
Refraction
Glasses change: gradual•Can be due to Diabetic shift in blood sugar
Cataract: blurry vision through glasses, glare while driving at night, haloes and starbursts
Retinal detachment: flashing lights, shower of new floaters, dark curtain over vision, blurred vision
Open angle glaucoma: no symptoms until late in the disease, high pressure in this case is painless
Range of Concerns and Diagnoses
Vitreous detachment: floaters in presence or absence of flashing lights, no vision loss, usually distinct floater(s)
Acute Angle Closure Glaucoma: Recent pupillary dilation, foggy vision
Range of Concerns and Diagnoses
Posterior Vitreous Detachment
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/weiss-ring.html
Bacterial conjunctivitis: pus-like discharge, eyes stuck shut in morning, usually children
Viral conjunctivitis: white/clear discharge, contact with someone else with a red eye, current or recent past upper respiratory infection, swollen, one or both eyes
Uveitis: sensitivity to light, redness Scleritis: extreme eye pain, extreme redness
Concerns and Diagnoses: PINK EYE
Allergic conjunctivitis: watering and itching of eyes, usually seasonal, current runny nose/cough/sneezing
Concerns and Diagnoses
Nerve palsy: symptoms only when both eyes open, certain gazes have less double than others, may have diabetes, hypertension, Graves, or other systemic diseases•May have lid droop, pupillary problem as
well
Concerns and Diagnoses: DOUBLE VISION
Acute angle closure glaucoma: vomiting, nausea, rainbows around lights, worse in morning, can be precipitated by dilation
Transient ischemic attack: blacked out vision lasting seconds to less than 5 minutes, returns to normal, typically older patients with history of high cholesterol•***IF symptoms coincide with unilateral
weakness, trouble findings speech or trouble ambulating, send patient immediately to ER
Concerns and Diagnoses
Foreign body: patient usually knows when it went in
Penetrating injury: high velocity, either patient or object, globe may be open, check immediately or send to ophthalmology if suspect
Endophthalmitis: extreme pain in the eye, usually after surgery or with other illness, send to ophthalmology
Concerns and Diagnoses
65 yo female calls with blurry vision FIRST question to ask:
•How long has the vision been blurry? Qualifiers
•How blurry is it?•Does anything make it better?•Has anything changed
Accompanying concerns•Flashing lights, floaters, diabetes
Patient #1
Vision blurry x 1 year Glasses help but not much Has glare and haloes with oncoming headlights
Diagnosis? Likely cataract, check next available
Patient #1 continued
5 yo male Red, painful eye For the last 2 days Got poked with a fake candy cane, went to urgent care, was given ointment, is sensitive to light
Likely diagnosis? Corneal abrasion, see same day if possible
Patient #2
45 yo male Blurry vision, both eyes
•Cobweb in the right eye yesterday, left eye now very fuzzy
Since yesterday the left eye has been very bad
Hasn’t seen any Dr. since 2009
Diagnosis: Proliferative Diabetic Retinopathy, see same day if possible
Patient #3
65 yo female Blurry vision, right eye, since yesterday
Proceeded by flashing lights/mild floaters
Now sees a curtain over vision
Likely diagnosis: Retinal detachment, see today
Patient #4
20 yo female Red, painful left eye Very sensitive to light, vision mildly blurred
Has systemic lupus
Likely diagnosis: Unilateral uveitis, see today or tomorrow
Patient #5
Finally!
Northwest Eye Surgeons is the premier eye surgical center in the Northwest and remains committed to its tradition of personalized, high quality patient care, advanced technology and excellent results.
SERVICES:CataractRefractive SurgeryGlaucomaCorneaPediatrics & StrabismusRetina, Vitreous & UveitisEyelid Surgery & Facial Rejuvenation
PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE
800.826.4631www.nweyes.com
Britta Hansen, OD, [email protected]