Managing common eye problems in general practice

Eye conditions are commonly encountered in primary care, but GPs often lack confidence with their diagnosis. This article gives an overview of some of the most common eye problems a GP might encounter and how they should be managed, including red flag symptoms to look out for when urgent referral is required.

Eye problems are common and for people worried about their sight, GPs are often the first port of call. Two million people in the UK have a sight problem and eye conditions account for up to 5% of all GP consultations.1 So we need a good working knowledge of eye problems but medical school training in ophthalmology is often rudimentary.2 Most medical students spend 5–10 days in total studying ophthalmology. Even experienced doctors often lack confidence and fail to notice important abnormalities when using a direct ophthalmoscope.3 In the UK, 96% of GPs do no postgraduate ophthalmology training and most say they do not feel confident carrying out assessments of the eye.1 The key to GPs managing eye conditions confidently is to recognise the red flag symptoms, work with local optometrists, use clinical guidelines for treatment, refer when appropriate and be aware of our limitations.

Should we abandon the ophthalmoscope?

Even experienced ophthalmologists can miss important abnormalities using a direct ophthalmoscope. But detecting abnormalities on examination may be critically important: disc swelling denotes raised intracranial pressure, signs of retinal artery occlusion may herald a preventable stroke, Roth spots (pale retinal lesions surrounded by haemorrhage, usually near the optic disc) are a sign of endocarditis.

Given the very limited teaching time given to eye conditions in medical schools, some experts argue that students should be taught to interpret images from fundus photography rather than “struggling to wield a direct ophthalmoscope”.3 A 1997 survey found that 43% of UK GPs lacked confidence in using the direct ophthalmoscope.2 There is no reason to think that this sorry situation has improved since then. Fundus photography is becoming cheaper and the quality is getting better; it is routinely used in screening diabetic patients for retinopathy and digital images can be sent to specialists for their advice. It is likely to become more widely used in general practice over the next few years.

What does the GMC require?

The GMC and Foundation Programme Curriculum state that fundus examination should be part of a complete examination but it needs to be reliable and accurate. Documenting “normal fundi” when you cannot be sure may lead to harm. Doctors are expected to take steps to ensure competence in fundal examination, but if uncertain, referral to a competent individual (a colleague, an optometrist or an ophthalmologist) is required. The dangers of inadequate examination were highlighted in the tragic case of eight-year-old Vinnie Barker who died of hydrocephalus, five months after a routine eye examination by optometrist Honey Rose, who failed to spot bilateral papilloedema.4 Rose was convicted of manslaughter through gross negligence.

The GMC states that GPs should:5
• Manage primary contact with all patients who have an eye problem
• Understand the common eye conditions in primary care and manage them appropriately
• Understand the importance of diabetic retinopathy screening and regular eye tests in the context of preventable sight loss
• Make timely, appropriate referrals on behalf of patients to specialist and community eye services.

Red flags

In reality, most common eye conditions will be easy to diagnose and straightforward to manage. However, benign and sight-threatening conditions can present very similarly. Red flag symptoms are relatively rare but GPs will be looking out for them in every patient who complains of an eye symptom or has a suspected systemic condition that may have eye signs. Any patient who has the following symptoms needs urgent referral:

• Sudden appearance of floaters, sudden short flashes of light in the eye, blurring or distortion of vision and a shadow or ‘dark curtain’ spreading across the vision: alert to retinal detachment, which will lead to blindness without prompt treatment.
• Abnormal pupillary reactions: may indicate acute glaucoma or anterior uveitis
• Moderate to severe eye pain or photophobia: could indicate acute uveitis, corneal ulcer, meningitis, eye injury or infection.
• Marked redness of one eye: the greater the redness, the more likely that the cause is serious. Ciliary injection, which is not always obvious, occurs with inflammation of deeper structures. It is indicated by redness, and dilated blood vessels that can be seen between the sclera (white of the eye) and the iris.
• Reduced visual acuity as measured with a Snellen chart or the near vision testing card: could suggest macular degeneration, glaucoma, cataract, diabetic retinopathy, optic neuritis or retinal detachment.
• Loss of peripheral vision: may indicate glaucoma, retinal vessel occlusion or detached retina.
• Seeing halos or rainbows around light: could indicate corneal oedema or cataract.
• Foreign body or penetrating eye injury.

Dry eyes

‘Dry eyes’ is a collective term for the discomfort, watering and blurring of vision that result from abnormal composition and production of tears and abnormalities of the surface of the eye. It is also called keratoconjunctivitis sicca, dry eye syndrome and dysfunctional tear syndrome. The cause may be too few tears produced, or too much evaporation from the ocular surface.

Dry eyes may not sound like a major problem, but it causes significant discomfort to the estimated 14.5% of the population who suffer from it.6 In some studies, up to 30% of those aged over 50 years report being affected.7 Sufferers rate it as affecting quality of life as much as people who suffer from angina or those on dialysis.8

Some distinct conditions such as Sjögren’s syndrome (an autoimmune condition affecting moisture-producing glands), allergic conjunctivitis and blepharitis (see below) can also cause similar symptoms. Sjögren’s syndrome should be suspected if dry eyes are accompanied by a dry mouth as it affects lacrimal and salivary glands.

Some people are more prone to dry eyes than others, for example, women, older people, and those with diabetes, Parkinson’s disease or low androgen levels. Dry eyes are also a known side-effect of certain medications, including antihistamines, anticholinergic drugs, oestrogens, amiodarone and isotretinoin. Contact lens wearers are especially at risk of dry eyes and some eye drops can cause drying. It can be a consequence of eye surgery, including the increasingly popular laser procedures to correct refractive errors. Air conditioning that reduces moisture in the air is a particular problem for some; the clue is that symptoms improve when the person gets away from the air-conditioned environment. Metabolic problems, including vitamin A deficiency, are an important cause, especially in developing countries.

Diagnosis is usually made on the basis of the history, including a patient questionnaire such as the Ocular Surface Disease Index (OSDI).9 More detailed examination by an ophthalmologist may be warranted, as traditional tests like Schirmer’s dry eye test (which uses paper strips to test for tear production) do not correlate well with symptoms.

Treatment aims to correct the underlying cause, boost tear production, slow tear evaporation or reduce reabsorption of tears. Artificial tears are usually the first line of treatment. They come as liquid, gel or ointment and many formulations are available over the counter. More expensive single-use, preservative-free preparations may be needed if there is an inflammatory reaction to the preservatives. A detailed review of the pros and cons of different types of artificial tears found some preparations were better than others (see Table 1).10

Table 1. Trials investigating the performance of artificial tears and their corresponding improvement in dysfunctional tear syndrome, based upon respective subjective and objective criteria10

Other strategies for managing dry eyes include:

• Encouraging frequent blinking, especially during visually attentive tasks such as reading or computer use.
• Minimising exposure to air conditioning or heating.
• Humidifiers in rooms where the patient spends a lot of time, eg the bedroom.
• Swim goggles or other ‘moisture chambers’ are recommended to protect the humidity of the local environment around the eyes. Moisture chambers can be purchased and fitted to current glasses by trained opticians.
• Ciclosporin eye drops can be effective but may cause a temporary burning sensation in the eye, are expensive and need to be initiated by a specialist.

Blepharitis

Blepharitis is a common and distressing condition that can be hard to manage.11 It is a chronic inflammatory disorder of the eyelids and adnexal structures (eyebrows, eyelashes and lacrimal glands). It causes burning, itching and a sensation of having something in the eye with crusting around the eyelashes. In severe cases, there may be corneal scarring and ulceration with eventual visual impairment.

Cleaning the eyelids with eyelid-specific soapy applicators several times a day and applying a warm compress to closed eyelids usually leads to symptomatic improvement. A topical corticosteroid and topical or oral antibiotics may also be necessary. Associated underlying medical conditions, such as rosacea, also need to be treated.

Red eyes occur most commonly due to conjunctivitis, which may be bacterial, viral or allergic. Other less common causes are shown in Table 2.

Table 2. Diagnosing the causes of red eye (click on table to view full-size)

The management depends on the underlying cause:12

• All cases of severe bacterial conjunctivitis should be treated with a topical antibiotic. Less severe cases that appear to be bacterial and are not resolving in one to two weeks should also be treated with a topical antibiotic. Drops may be preferable to ointment, which may be hard to use.13
• In allergic conjunctivitis, patients should be advised to avoid exposure to allergen and to apply cool compresses. An oral or topical antihistamine or topical mast cell stabiliser can be prescribed.
• Red eye caused by infective conjunctivitis can be contagious. Washing hands and avoiding use of contaminated tissues or washcloths helps prevent spread to the other eye or to other individuals.
• Suspected scleritis requires referral; treatment is usually an NSAID such as diclofenac 50mg orally three times daily. Episcleritis is usually self-limiting.
• Suspected cases of anterior uveitis should be seen by an ophthalmologist within one to two days. Topical steroids are prescribed by an ophthalmologist, with cycloplegic agents, eg atropine, to paralyse the ciliary muscle in order to prevent synechiae (when the iris adheres to cornea).
• For keratitis, antibiotic eye drops or the appropriate topical antiviral agent are prescribed by an ophthalmologist.
• Angle-closure glaucoma (acutely raised intraocular pressure associated with a physically obstructed anterior chamber angle) is a medical emergency that may lead to blindness.14 Prompt expert assessment is needed via accident and emergency or the emergency eye department. Treatment consists of miotic drops, eg pilocarpine, every five minutes up to one hour, acetazolamide orally or intravenously, antiemetics, analgesia, and, in some cases, IV mannitol.15 Peripheral iridotomy, usually performed with a YAG laser, can cure the problem.
• Cases of subconjunctival haemorrhage with no history of trauma do not need treatment. Artificial tears can be soothing.
• Corneal or conjunctival foreign bodies need to be removed.

References

1. Kilduff C, Lois C. Red eyes and red-flags: improving ophthalmic assessment and referral in primary care. BMJ Qual Improv Report 2016;5:doi:10.1136/bmjquality.u211608.w4680.
2. Shuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology. Eye 1997;111:744–50.
3. Purbrick RMJ, Chong NV. Controversy: Direct ophthalmoscopy should be taught to undergraduate medical students – No. Eye 2015;29:990–1.
4. Press Association. Optometrist who missed swelling in boy’s brain guilty of manslaughter. The Guardian 15 July 2016. https://www.theguardian.com/uk-news/2016/jul/15/optometrist-honey-rose-guilty-manslaughter-negligence-vinnie-barker-boots
5. Royal College of General Practitioners. RCGP Curriculum 2010. 3.16 The clinical example on care of people with eye problems. Revised August 2013. http://www.gmc-uk.org/3_16_Eye_problems_August_2013.pdf_55925974.pdf
6. Paulsen AJ, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors and health-related quality of life. Am J Ophthalmol 2014;157(4):799–806.
7. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007;5(2):93–107.
8. Schifman RM, et al. Utility assessment among patients with dry eye disease. Ophthalmology 2003;110(7):1412–9.
9. Dougherty BE, et al. Rasch analysis of the ocular surface disease index (OSDI). Invest Ophthalmol Vis Sci 2011;52(12):8630–5.
10. Moshirfar M, et al. Artificial tears potpourri: a literature review. Clin Ophthalmol 2014;8:1419–33.
11. NICE Clinical Knowledge Summaries. Blepharitis. October 2015. cks.nice.org.uk/blepharitis
12. NICE Clinical Knowledge Summaries. Red eye. October 2016. cks.nice.org.uk/red-eye
13. Graham RH, et al. Red eye treatment and management. Medscape 15 January 2016. http://emedicine.medscape.com/article/1192122-treatment#d10
14. NICE. Glaucoma overview. pathways.nice.org.uk/pathways/glaucoma
15. Freedman J, et al. Acute angle-closure glaucoma treatment and management. Medscape 22 August 2016. http://emedicine.medscape.com/article/798811-treatment

Declaration of interests

None to declare.

Dr Robinson is a GP and health writer

Managing common eye problems in general practice

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