The role of the GP in the care of people with eye and vision problems
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.
Emerging issues in the care of people with eye and vision problems
- 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.
Knowledge and skills guide
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.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do I feel about telling Ibrahim that he must not drive his car? |
An ethical approach This is about practicing ethically with integrity and a respect for equality and diversity. | What would I do if he drives the car against my advice? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How can I explore the psychological impact of visual loss in the consultation with Ibrahim? How would I explain the likely outcome of his condition? What do I think might be the obstacles to Ibrahim having regular eye tests? How would I explore all those issues? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What lifestyle factors would I record in the notes? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | Why should I use a pinhole when assessing visual acuity? When is an Amsler grid useful in assessing a patient? How confident do I feel performing fundoscopy? How could I improve my clinical examination skills in this area? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What other blinding eye conditions present with gradual onset? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | Which of my patients are entitled to free eye tests under the NHS? How easy is it to arrange for my patients to receive an eye test at home? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What comorbidities are common with sight loss? What are the risk factors for age-related macular degeneration (ARMD/AMD) and how common is it? What role has Ibrahim’s bereavement played in this scenario? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How urgent is this hospital referral? What role does an optician play in caring for patients with eye conditions? How can I collaborate with local opticians to provide a better service for my patients? Can I read the GOS (General Ophthalmic Services) letter from the optician and understand what the different terms mean? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What are the current issues around treating AMRD? How do I keep myself updated about ophthalmological conditions? How confident am I in using an ophthalmoscope? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How should I ensure that my patients are not ‘lost to follow-up?’ What does the practice provide to support visually impaired patients? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How will I manage the psychological impact of sight loss in Ibrahim? Why do I think Ibrahim did not seek help earlier for the problems with his vision? What do I know about Ibrahim’s living accommodation? Will he need additional support at home? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What social benefits and services might be available to this patient and his carers if he is certified visually impaired? Where do I find the DVLA rules on sight impairment and who is required to inform the DVLA? What other health professionals in the community could help in managing Ibrahim’s vision problems? |
How to learn this area of practice
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.
Examples of how this area of practice may be tested in the MRCGP
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