Surgery notes
with Dr Graham Easton

21 January 2008

Eye problems

I've recently done a two-day course on eye problems for GPs at Moorfields Eye Hospital, London. It was a fascinating glimpse of cutting edge ophthalmology and a chance to get expert tips on the more common eye problems I see every day in general practice - simple infections and specks in the eye to sight-threatening problems such as glaucoma and diabetic eye disease.

Examining eyes

My medical school only provided a few days' training in ophthalmology. I learnt the rest on the job in A&E and training to be a GP. One of the drawbacks of dealing with eye problems in general practice is that most GPs have only basic equipment with which to examine the eye.

The average hand-held ophthalmoscope, even in expert hands, can only tell you so much. But knowing how to examine the eye with only basic equipment is an important skill in general practice, particularly for doctors working in remote locations. Many GPs on the course leapt at the chance of a practical session on how to use the instrument effectively.

It's vital to turn the upper eyelid inside out (eversion), which is easier than it sounds and not at all painful

One tip was to use special eye drops to dilate the pupil. This gives a much better view of the blood vessels at the back of the eye (the retina). Looking at the retina is important in diabetes. People with the condition are at risk from retinopathy, damage to the tiny blood vessels in the retina. If left untreated, it can cause visual loss or even blindness.

GPs still need to be alert to retinopathy, but the NHS now offers people with diabetes regular eye tests using special equipment that takes photographs of the retina. If detected in time, retinopathy can often be treated using a laser.

People often come to the surgery with the feeling that they've got something in their eye, or they've scratched their eye somehow. We were reminded about some of the key elements of an examination in this case.

First, it's vital to turn the upper eyelid inside out (eversion), which is easier than it sounds and not at all painful. If we don't do this it's easy to miss a speck lurking under the eyelid that can scratch away at the surface of the eye causing pain and damage.

It's also important to put stain drops into the eye, which can show up a scratched surface or even an infective ulcer. If we do spot something that shouldn't be there, it's possible to remove it using a hypodermic needle with the tip bent over.

The advice was to only try this if we felt confident in the technique, and to put some anaesthetic drops in the patient's eye first.

Common eye problems

Conjunctivitis

GPs see a lot of conjunctivitis, which is an inflammation of the thin skin (conjunctiva) that covers the whites of the eyes and inside of the eyelids. The eye becomes red or pink, may be sticky or watery, and the surface of the eye is often irritated.

It's usually caused by one of three things: infection (a virus or bacteria), allergy or irritation. In general practice it's often hard to distinguish confidently between the three, but the course taught us some useful pointers.

As always, history is vital - itching is the cardinal symptom of allergic conjunctivitis and eyelids stuck together on awakening suggests a bacterial infection. In adults, wearing contact lenses is a common cause of allergy. When it comes to examination, a swollen lymph node in front of the ear is highly suggestive of viral conjunctivitis.

Fortunately, most cases of conjunctivitis clear up within a few days. Although we often give antibiotic drops, they're not always needed. We were reminded of when we should refer people with suspected conjunctivitis to eye specialists - mainly when things aren't settling as expected or when there are symptoms that don't quite tally.

Glaucoma

This is damage to the optic nerve, usually caused by increased pressure within the eye. A video showing what a patient with glaucoma might see (or not) gave me a rare insight into the condition and has given me a new perspective on the disease.

Far from being the 'sneak thief' that suddenly steals your eyesight unannounced, glaucoma can cause many problems as it develops. In particular, the blind spots it creates can cause trips and falls, and difficulty finding things that have been dropped on the floor.

Blepharitis

This is the most common eye disease. It's a chronic inflammation of the eyelids but its cause isn't known. It's a real nuisance for patients and is often difficult to treat. The expert angle seems to be an attack on several different fronts (often the case when there isn't a clear cause).

It can be worth trying tetracycline antibiotics for several months. These probably work by dampening down the inflammation that causes the problems rather than treating any infection.

In addition, hot flannels on the eyelids and massaging the lids in a downward motion using your finger as a sort of steamroller can help to empty any blocked glands. GPs should also advise patients to keep the free edge of their lids clean using the tip of a cotton bud soaked in diluted baby shampoo.

Cutting edge

An important part of a course for GPs is to hear about some of the procedures we refer our patients for but rarely get to see ourselves.

We learnt about cataract surgery - one of the most common elective surgical procedures. Modern cataract surgery is done almost exclusively using small incision surgical techniques, which have reduced risks and complications.

At the most advanced level, patients are offered a choice of lens implants, including new accommodating lens implants or multifocal lens implants that can reduce dependence on reading glasses and give high-quality distance vision without glasses.

There are changes afoot in the UK that should allow high-street optometrists to refer patients directly to a specialist for cataract surgery, once again leaving the GP out of the loop.

There are changes afoot in the UK that should allow high-street optometrists to refer patients directly to a specialist for cataract surgery

It was fascinating - although for me a little stomach churning - to see videos of the latest techniques in refractive surgery. This is where lasers are used to alter the curve at the front of the eye, changing the eye's focusing power and allowing patients to do without glasses.

In the early days of this technique, it was mainly people such as special forces soldiers, pilots and TV presenters who opted for the operation, but it's becoming more and more popular. In the hands of a properly trained and skilled operator, the risk of serious damage to the eye using this technique is about the same as wearing contact lenses for four years.

With other useful sessions on squints, sudden loss of vision, age-related macular disease and even a photo quiz competition, it was two days that should benefit both me and my patients. Like most professionals, I have to keep up to date. Going on a course can be inconvenient for patients because I'm out of the surgery, but in the long run it's an efficient way of staying up to speed

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