practical ophthalmology for gps: glaucoma mr kuang hu ma mb bchir phd (cantab) frcophth consultant...
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Practical Ophthalmology for GPs: Glaucoma
Mr Kuang HuMA MB BChir PhD (Cantab) FRCOphthConsultant Ophthalmic Surgeon
9 October 2014
www.moorfields.nhs.uk
• What is glaucoma?• Management of glaucoma• Differential diagnosis of acute glaucoma• Referral pathways
Glaucoma
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Blinding
•2nd biggest cause of blindness worldwide•Functional deficit, handicap, disabilityCommon
•Affects more than 1 in 100 of 40+ years old
•10% of Croydon patients have it, or are at risk
What is Glaucoma?
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People don’t notice until it’s too late
•Visual loss is painless and progressive
•Exception is acute glaucoma
What is Glaucoma?
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What is Glaucoma?
Group of diseases with common features:
• Eye pressure is too high
• Damage to the optic nerve
• Damage to vision
• Treatment is to lower eye pressure
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What is Glaucoma?Spectrum of damage to vision
• Mild: minimal visual lossno handicap or disability
• Severe: tunnel visiontrips, can’t drive
• End stage: ‘blind’can’t read, can’t see TV
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Acute rapid rise in pressure
Chronicgradual rise in pressure
Two types of glaucoma
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HistoryHistory HoursHours Severe painSevere pain NauseaNausea
ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Hazy CorneaHazy Cornea Rock hard eyeRock hard eye
Acute glaucomaAcute glaucoma
Refer immediatelyRefer immediately
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Chronic glaucomaPainless
Gradual loss of vision
White eye
Previous diagnosis
Already on drops
Management of Management of GlaucomaGlaucoma
IdentifyIdentify Acute glaucoma: 1 case every 3-10 yearsAcute glaucoma: 1 case every 3-10 years Definite chronic glaucomaDefinite chronic glaucoma Possible chronic glaucoma – ‘suspects’Possible chronic glaucoma – ‘suspects’ High risk of chronic glaucoma – raised pressureHigh risk of chronic glaucoma – raised pressure
Management of Management of GlaucomaGlaucoma
IdentifyIdentify Pressure measurementPressure measurement PachymetryPachymetry GonioscopyGonioscopy Visual field testVisual field test Slit-lamp stereoscopic examination of optic discSlit-lamp stereoscopic examination of optic disc Imaging of optic discImaging of optic disc
TreatTreat Lower eye pressureLower eye pressure Prevent further damage to optic nervePrevent further damage to optic nerve Prevent progression of visual lossPrevent progression of visual loss Prevent disability and handicapPrevent disability and handicap
MedicationsMedications
LaserLaser
SurgerySurgery
Management of Management of GlaucomaGlaucoma
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Management of GlaucomaMedication• Eye drops (5 classes)• Oral, intravenous
Laser• Selective laser trabeculoplasty• YAG laser iridotomy• Argon laser iridoplasty• Diode laser cycloablation
Surgery• Minimally-invasive, eg Trabectome (NICE)• Lens extraction• Trabeculectomy with cytotoxic antiscarring agents• Aqueous shunt ‘tube’ surgery (several types)
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Management of Glaucoma
Two basic types
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Management of Glaucoma
Two basic types
Chronic
• Gradual rise in pressure
• Painless
• White eye
• Gradual visual loss
• Treatment with drops
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Management of Glaucoma
Two basic types
Chronic
• Gradual rise in pressure
• Painless
• White eye
• Gradual visual loss
• Treatment with drops
• Please prescribe drops
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Management of Glaucoma
Two basic types
Chronic Acute
• Gradual rise in pressure • Sudden rise in pressure
• Painless • Acutely painful
• White eye • Red eye
• Gradual visual loss • Rapid visual loss
• Treatment with drops • Drops, IV drugs, laser
• Please prescribe drops
www.moorfields.nhs.uk
Management of Glaucoma
Two basic types
Chronic Acute
• Gradual rise in pressure • Sudden rise in pressure
• Painless • Acutely painful
• White eye • Red eye
• Gradual visual loss • Rapid visual loss
• Treatment with drops • Drops, IV drugs, laser
• Please prescribe drops • Recognize and refer as EMERGENCY
www.moorfields.nhs.uk
Management of Glaucoma
Two basic types
Chronic Acute
• Gradual rise in pressure • Sudden rise in pressure
• Painless • Acutely painful
• White eye • Red eye
• Gradual visual loss • Rapid visual loss
• Treatment with drops • Drops, IV drugs, laser
• Please prescribe drops • Recognize and refer as EMERGENCY
www.moorfields.nhs.uk
Management of Glaucoma
Two basic types
Chronic Acute
• Gradual rise in pressure • Sudden rise in pressure
• Painless • Acutely painful
• White eye • Red eye
• Gradual visual loss • Rapid visual loss
• Treatment with drops • Drops, IV drugs, laser
• Please prescribe drops • Recognize and refer as EMERGENCY
www.moorfields.nhs.uk
Management of Glaucoma
Two basic types
Chronic Acute
• Gradual rise in pressure • Sudden rise in pressure
• Painless • Acutely painful
• White eye • Red eye
• Gradual visual loss • Rapid visual loss
• Treatment with drops • Drops, IV drugs, laser
• Please prescribe drops • Recognize and refer as EMERGENCY
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Acute Glaucoma?
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Differential Diagnosis of Acute Glaucoma
•Infective conjunctivitis
•Subconjunctival haemorrhage
•Iritis
•Acute glaucoma•Endophthalmitis
•Orbital cellulitis
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1-minute ophthalmic assessmentHistory• Acute or chronic• Severity of pain• Other symptoms, past ophthalmic history
Examination• Acuity• Lids• Conjunctiva• Cornea• If possible: Pupils, pressure
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HistoryHistory SpontaneousSpontaneous Mild painMild pain Mild blurringMild blurring
ExaminationExamination Looks like bloodLooks like blood
1-minute ophthalmic assessmentSubconjunctival haemSubconjunctival haem
Conservative: BP, INRConservative: BP, INRRefer if not resolvingRefer if not resolving
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HistoryHistory DaysDays Mild painMild pain Sticky dischargeSticky discharge
ExaminationExamination Mild blurringMild blurring Mild swelling lidsMild swelling lids Red conjunctivaRed conjunctiva Clear corneaClear cornea Normal pupilsNormal pupils
1-minute ophthalmic assessmentConjunctivitisConjunctivitis
Chloramphenicol eye drops Chloramphenicol eye drops QDS for 1 weekQDS for 1 week
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HistoryHistory Days or weeksDays or weeks Moderate painModerate pain PhotophobiaPhotophobia
ExaminationExamination Moderate blurringModerate blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Clear corneaClear cornea Unreactive pupilUnreactive pupil
1-minute ophthalmic assessmentIritisIritis
Refer within 24 hoursRefer within 24 hours
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HistoryHistory HoursHours Severe painSevere pain NauseaNausea
ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Hazy corneaHazy cornea Rock hard eyeRock hard eye
1-minute ophthalmic assessmentAcute glaucomaAcute glaucoma
Refer immediatelyRefer immediately
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HistoryHistory HoursHours Severe painSevere pain Recent surgeryRecent surgery
ExaminationExamination Severe blurringSevere blurring Normal lidsNormal lids Red conjunctivaRed conjunctiva Normal CorneaNormal Cornea HypopyonHypopyon
1-minute ophthalmic assessmentEndophthalmitisEndophthalmitis
Refer immediatelyRefer immediately
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HistoryHistory Severe painSevere pain Loss of visionLoss of vision Double visionDouble vision
ExaminationExamination Loss of visionLoss of vision Unreactive pupilUnreactive pupil Reduced motilityReduced motility ProptosisProptosis
1-minute ophthalmic assessmentOrbital cellulitisOrbital cellulitis
Refer immediatelyRefer immediately
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Differential diagnosis of Acute Glaucoma
Use the 1-minute ophthalmic assessmentDiagnosis Management•Subconjunctival haem Conservative•Conjunctivitis Chloramphenicol•Iritis Refer within 24 hrs•Acute glaucoma Refer immediately•Endophthalmitis Refer immediately•Orbital cellulitis Refer immediately
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Referral pathwaysUrgent = Telephone 020 8401 3486
Routine = Referral letter
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Summary
Glaucoma is a sight-threatening disease
Acute glaucoma is rare, but has common mimics
Chronic glaucoma is common
Identifying chronic glaucoma requires many tests
Treatment is by lowering eye pressure
Moorfields is here to help
Practical Ophthalmology for GPs: Glaucoma
Mr Kuang HuMA MB BChir PhD (Cantab) FRCOphthConsultant Ophthalmic Surgeon
9 October 2014