Eyes and vision

As a GP your role is to:

• understand how visual loss and impairment can be a significant cause of physical and psychosocial morbidity, which can be a barrier to accessing healthcare. This can be mitigated by appropriate rehabilitation for visually impaired patients
• coordinate access to community and secondary care services
• undertake opportunistic health screening, ensuring that patients have regular eye tests and are referred appropriately and in a timely manner
• recognise how sight loss can interfere with mobility and lead to social isolation and difficulty in communication (such as use of telephones or computers), as well as the impact of poor eye health on confidence, mental health, activities of daily living, independent living and ability to work
• take a focused history, examine, diagnose and treat common eye conditions and know when to refer to specialist care.

• Eye disease impacts significantly on GP consultations and has wider social and economic consequences.
• Treating eye problems and effective screening are having an impact on the number of people with sight loss but there is much more to be done.
• Caring for those with sight loss goes beyond knowing which referral pathway should be used. GPs need to know how to access rehabilitation, low-vision aid services and help for patients to continue to live independently, and how to make general practices and written information accessible for those with poor vision.
• Sight loss occurs in conjunction with other complications of multiple morbidity and can make other aspects of care (such as being able to take medication safely) more complicated. People who cannot see may lose their non-verbal communication skills, and this should not affect or prejudice your interactions with or attitude to them.
• In the UK, the prevalence of sight loss due to cataract, macular degeneration, glaucoma and diabetic retinopathy is increasing as the population ages. Difficulties with reading small print, cooking, mobility, taking medication and recognising faces may be missed unless a careful history is taken. Visual acuity, contrast sensitivity and visual fields may be affected.

For each problem or disease, consider the following areas within the general context of primary care:

• the natural history of the condition, including whether acute or chronic
• the incidence and prevalence, including in different demographic groups
• typical and atypical presentations
• recognition of normal variations throughout life
• risk factors, including lifestyle, socio-economic and genetic factors
• diagnostic features and differential diagnosis
• recognition of ‘alarm’ or ‘red flag’ features
• appropriate and relevant investigations
• management, including initial and continuing care, chronic disease monitoring and emergency care
• patient and carer information and education including self-care prognosis.

Symptoms and signs

• Colour blindness, changes in colour vision
• Diplopia, squint and amblyopia
• Discharge from the eye
• Dry eyes
• Entropion or ectropion
• Eyelid swellings
• Excessive watering of the eye (epiphora)
• Falls
• Orbital swellings
• Red eye: painful or painless
• Visual disturbance: complete or partial loss of vision, distorted vision, floaters, flashes
• Visual field disturbance

Investigations

• Performing and interpreting fundoscopy, visual acuity tests and results, red reflex testing, visual field tests, Amsler charts
• Interpreting tonometry, optician reports and tests of colour vision
• Examining eyes for foreign bodies, and corneal staining with fluorescein
• Key blood tests (for example, for giant cell arteritis)

Common and important conditions

• Cataracts – congenital or acquired (such as drug-induced)
• Colour blindness
• Congenital, neonatal and childhood eye problems, such as prematurity, congenital cataract, vitamin A deficiency
• Conjunctivitis, including infectious causes (bacterial, viral, parasitic and chlamydial) and allergic causes
• Contact lens use, including infections such as acanthamoeba, corneal damage
• Diabetic eye disease
• Disorders of tears and tear ducts such as dacrocystitis, sicca syndrome, epiphora, dry eyes
• Disorders of the pupil such as Horner’s syndrome, Holmes-Adie syndrome
• Dual sensory impairment and loss (vision and hearing)
• Episcleritis, corneal or dendritic ulcers, pterygium, pinguecula, corneal injury and erosions
• Eye trauma, including penetrating trauma, corneal abrasions, chemical burns, contusions, hyphaema
• Eyelid problems such as blepharitis, ectropion, entropion, chalazion, meibomian cysts, styes
• Genetic eye problems such as retinoblastoma, retinitis pigmentosa
• Glaucoma – acute, closed angle and chronic open angle
• Intracranial pathology affecting vision
• Keratitis, including association with other diseases such as rosacea, thyroid disease
• Keratoconus
• Loss of vision or visual disturbance; differential diagnoses and appropriate management, including timescale of urgency
• Macular degeneration – age-related (wet and dry), drusen
• Malignancy such as retinoblastoma, lymphoma, melanoma
• Ophthalmic herpes zoster
• Ophthalmic manifestations of infections such as syphilis, tuberculosis (TB), toxocariasis, toxoplasmosis
• Optic neuritis and neuropathy
• Orbital infections such as cellulitis, tumours
• Red eye – differential diagnoses and appropriate management, including timescale of urgency
• Refractive error, including myopia, hypermetropia, astigmatism
• Retinal problems including:
  • atrophy
  • detachment
  • haemorrhage, exudates, blood vessel changes associated with systemic diseases such as hypertension, diabetes, haematological diseases thromboses or emboli
  • tumours such as melanoma, neuroblastoma
  • vascular lesions
• Squint – childhood and acquired due to nerve palsy, amblyopia, blepharospasm
• Subconjunctival haemorrhage
• Systemic diseases with associated eye symptoms and signs, such as hypertension, diabetes, raised intracranial pressure, multiple sclerosis, sleep apnoea, giant cell arteritis
• The effect of stroke and migraine on vision
• Thyroid eye disease
• Uveitis, including knowledge of underlying associations such as inflammatory bowel disease, connective tissue diseases
• Vitreous detachment

Service issues

• Appropriate and cost-effective prescribing (for example, eye drops and biological therapies)
• Accessibility of clinic premises for people with visual impairment
• Compliance with the Accessible Information Standard, for example providing information in audio, Braille, large print, or audio format
• Benefits of certification of visual impairments and how this enables access to benefits, and local authority assessment of need
• The level of visual deficit required before certification of visual impairment can be issued
• Guide Dogs for the Blind Association
• Liaison with other agencies and reminder systems to ensure appropriate follow-up of eye conditions
• Local NHS guidance on funding for certain treatments (such as cataract surgery)
• Relevant policies and legislation (including disability)
• Restrictions on driving and employment, including DVLA (Driver and Vehicle Licensing Agency) guidance for visual acuity
• Services available to those with vision problems; from acute hospital to community optician, support from charities and the third sector
• Types of low-vision aids available (such as large print, audio, magnifiers, long cane, Braille)

Case discussion

It is Monday morning, and your second patient is Ibrahim Mirza, who is 75 years old. He was last seen six months ago regarding his problems with sleeping. He has lived alone since his wife died suddenly from a stroke three years previously.

He is accompanied by his daughter, who you have not met before. She tells you that her dad has asked her to come along as he is a bit upset since his visit to his optometrist last week. Ibrahim says, ‘It was not the girl I usually see at the optician. This man flashed a lot of lights in my eyes then said I had a major problem with my vision and should come to see you about going to the hospital. What’s worse is that he said I shouldn’t drive my car.’ His daughter adds, Dad was so upset he didn’t even ask what was wrong. His car is his lifeline. I went back with him to the optician, and they told me he probably has something called ARMD – he wrote it down for me.’

Ibrahim has no relevant previous history; he is not taking any medication and comes in regularly for his flu jab and health checks with the nurse. He had noticed his vision was deteriorating but assumed this was because he needed new glasses; that was why he went for an eye check. He says, ‘I don’t go out at night any more as I can’t see well enough. I also noticed a funny thing – I can see the television better when I look from the side rather than from the front.’

The optometrist noted a marked loss of visual acuity since Ibrahim’s last eye examination and feels that this is likely to be due to age-related macular degeneration. You advise Ibrahim that you will refer him to the local eye department and print off some information regarding eye charities in large print, which he can read while he awaits his appointment.

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

Work-based learning

In general practice you can learn how to manage eye problems within the limited time and resources available. You should also take the opportunity to find out about other agencies, both statutory and voluntary, that provide support for patients with chronic eye disorders in the community.

As a GP registrar, you should try, if possible, to attend some secondary care-based ophthalmology clinics and/or eye emergency units to learn about both acute and chronic conditions and how to conduct a thorough eye assessment. It would also be useful for you to attend an operating session to gain an understanding of cataract surgery, perhaps by accompanying a patient on their journey.

Self-directed learning

You can find an eLearning module(s) relevant to this topic guide at e-learning for healthcare and RCGP eLearning.

The Royal National Institute of Blind People (RNIB) has a helpful website, including GP- related resources. The DVLA offers guidelines on assessing fitness to drive and the Royal College of Ophthalmologists has a range of patient information booklets on common eye conditions.

Learning with other healthcare professionals

Optometrists are key members of the primary healthcare team and are increasingly involved in working in partnership with GPs in the management of diabetic patients and in screening for glaucoma and other eye problems. Meeting with them provides an excellent opportunity for discussing the impact of chronic eye problems and issues of screening and prevention. As a GP registrar you should attend your local optometrist to gain a better understanding of their skills and their contribution to primary care teams.

Structured learning

Specific workshops may be run by local hospitals or your RCGP faculty, for example.

Applied Knowledge Test (AKT)

• Differential diagnosis of causes of an acute red eye
• Recognition of serious eye disease in a retinal photograph
• Interpretation of visual field charts

Simulated Consultation Assessment (SCA)

• An elderly man has a rapid deterioration in vision over the past month; examination expected (Snellen charts supplied)
• A gardener has troublesome allergic conjunctivitis and hay fever despite using over-the-counter eye drops and antihistamine tablets
• A schoolteacher presents with a painful eye and blurred vision; examination (photo provided) suggests uveitis

Workplace-based Assessment (WPBA)

• Log entry reflecting on the local optician who frequently requests hospital referrals for patients
• Log entry about a tutorial on ‘acute red eye’ and your subsequent management of the next three patients with this symptom
• Consultation Observation Tool (COT) about an elderly woman who has watering eyes