cpd10 (watery, itchy & gritty eye) (10 sep 10)

8/12/2019 CPD10 (Watery, Itchy & Gritty Eye) (10 Sep 10)

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OP2CPD

Clinical Practice Development

Watery, itchy & gritty eye(s)

Mark Dunne & Bhavna Prajapati


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Learning objectives

This lecture has been written to teach you:

A problem-orientated approach to a patient complaining of watery, itchy &gritty eye(s) or foreign body sensation

What you should ASKLOFTSEA, laterality, other symptoms (soreness, irritation, pain,photophobia, blurred vision), ocular history, medical history, family

historyWhat you should LOOK FOR

Visual acuity, external examination (eyelids, tears, lacrimal drainage,conjunctiva, cornea)

Further procedures (slit lamp biomicroscopy with Fluorescein, eyelid

eversion & dry eye tests such as TBUT, tear meniscus, Schirmer test,Lissamine green test)

About the PLANTreatment, advice, referral urgency (immediate, same day, urgent1

week, urgent2 weeks, soon1 month, routine)

Factors that influence referral


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Revision tips

Exams WILL test you on:

What you need to ASK

What you need to LOOK FOR

SYMPTOMS & SIGNS that indicate

serious disease & raise referral

urgencySYMPTOMS, SIGNS & REFERRAL

URGENCIES of some serious eye

diseases

Concentrate on information given in:

BLACK TYPE SCRIPT

PURPLE TYPE SCRIPTNo need to revise:

Lists of diseases shown in BLUE

TYPE SCRIPT


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SOAP (Revision)

Subjective

Case history

ASK for

Symptoms & signsObjective

LOOK for

Signs

Analysis

Differential diagnosis

During subjective & objective

Plan

Advice/treatment/referral

Urgency


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Legal requirements (Revision)

This lecture:

Applies SOAP (problem-

orientated approach)

Leads to a more purposefulexamination

Examination MUST also meet legal

requirements

Cover all oculovisual systems:

VisualBinocular

Refractive

Ocular health

Case History

(all systems)

Visual acuity

(visual, refractive, ocular health)

Cover test, motility, convergence(binocular)

Pupil responses

(binocular, ocular health)

Ophthalmoscopyexternal & internal

(ocular health)

Refraction & near add determination(refractive)

Tonometry

(ocular health)

Visual fields

(visual)


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Overview

Many conditions present with WATERY, ITCHY or

GRITTY EYE(S)

Allergic conjunctivitis, dry eye, blepharitis,

ectropian, trichiasis, age-related nasolacrimal

duct obstruction, punctal stenosis, foreign body(on cornea, under eyelid), corneal ulcer

Note:These complaints suggest an ocular surface

problem, - so slit lamp examination required

with systematic examination of eyelids, tears,

lacrimal drainage, conjunctiva and cornea(including fluorescein instillation)

Think of commonest conditions first (eg allergic

conjunctivitis) but also consider rarer conditions

(eg corneal ulcer)


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LOFTSEA (Revision)

Location & laterality

OnsetFrequency & occurrence

Type & severity

Self-treatment (effectiveness)

Effect on patient

Associated or secondarysymptoms


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Subjective (ASK)presenting symptoms

Watery eye(s)?Examples: allergic conjunctivitis, dry

eye, blepharitis, ectropian, trichiasis,

age-related nasolacrimal duct

obstruction, punctal stenosis, foreignbody (on cornea, under eyelid),

corneal ulcer,

Itchy eye(s)?

Examples: allergic conjunctivitis, dry

eye

Gritty eye(s)?Examples: dry eye, blepharitis

Foreign body sensation?

Examples: dry eye, blepharitis,

trichiasis, foreign body (on cornea,

under eyelid), corneal ulcer

Case History

(all systems)

Visual acuity



Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)


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Subjective (ASK)notes on presenting symptoms

Often most common but least serious

complaints

Watery eye(s)think about:

Reflex tearing caused by irritation

(dry eye can cause irritation)Lacrimal drainage problem in old

age

Itchy eye(s)think about:

Often due to allergic conjunctivitis

Ask if problem is seasonal

Gritty eye(s)think about:

Often due to dry eyes associated

with chronic blepharitis

Foreign body sensation?

Ask if something blew into eye

Case History

(all systems)

Visual acuity



Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)


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Subjective (ASK)laterality (LOFTSEA)

One eye?

Examples: ectropian, trichiasis,

age-related nasolacrimal duct

obstruction, punctal stenosis,

foreign body (on cornea, under

eyelid), corneal ulcer

Both eyes?Examples: allergic conjunctivitis, dry

eye,blepharitis, ectropian,

trichiasis, age-related nasolacrimal

duct obstruction, punctal stenosis

Caution:

The most serious conditions (eg

corneal ulcer) tend to affect one

eye

Case History

(all systems)

Visual acuity


Cover test, motility, convergence

(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)


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Subjective (ASK)Other symptoms (LOFTSEA)

Sore or irritated eyes?


eye, blepharitis,ectropian,

trichiasis,foreign body under eyelid

Most relevant to watery eye(s)Pain & photophobia?

Examples: foreign body on cornea,

corneal ulcer

Blurred vision?

Examples: dry eye, foreign body on

cornea, corneal ulcerNote:

Pain, photophobia & blurred

vision indicate serious problem

or raise referral urgency

Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)


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Contact lens wear

Risk factor for corneal abrasion

or ulcer that may cause foreign

body sensation or watery eye

Allergy to cleaning solutions may

cause itchy eyes (allergic

conjunctivitis)

Use of eye drops

Allergy to these may cause itchy

eyes (allergic conjunctivitis)Previous eye surgery

A broken suture may cause

foreign body sensation or watery

eye

Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Subjective (ASK)ocular history


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Subjective (ASK)medical history

Asthma, eczema, hay fever?

Indicates allergicconjunctivitis, causing itchy

eyes, in a person prone to

allergies

Rheumatoid arthritis

May be associated with dry

eye & non infectious corneal

ulcer


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Subjective (ASK)family history

Hayfever?There is often a family

history of hay fever in

sufferers of allergic

conjunctivitis


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)visual acuity

Referral letters require:

Unaided distance visionVisual acuity distance and

near

Previous visual acuity

Pinhole test

Rules out ametropia if blurred

vision is reported


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)binocular system

Covers legal requirements

Of little diagnostic value here


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)pupil responses




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Case History

(all systems)

Visual acuity



Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)external

Systematic examination of

eyelids, tears, lacrimal

drainage, conjunctiva,

cornea


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Objective (LOOK FOR)external (eyelids)

Slit lamp examination preferable

Blepharitis

Lid swelling (if severe), red lid

margins, blocked tarsal gland

openings, scales on lashes,

loss of lashes

Causes watery eye(s), gritty

eye(s) & foreign body

sensation

(Source: Kanski)


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Slit lamp examination preferableEctropion

Lower eyelid turned outwards

Lacrimal puncta held in wrong

position

Causes watery eyes

(Source: Kanski)


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Slit lamp examination preferableTrichiasis

Inturned eye lashes

Often due to blepharitis

Causes watery eye(s) &

foreign body sensation

(Source: http://dro.hs.columbia.edu/op1/trichiasis2b.jpg)


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Objective (LOOK FOR)external (tears)

Slit lamp examination with

Fluorescein preferable

Dry eye

Unstable tear film (various

signs including poor TBUT,

poor tear meniscus, frothing

of tears near lid margin)

Causes watery, itchy & grittyeye(s) plus foreign body

sensation(Source: Kanski)


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Objective (LOOK FOR)external (lacrimal drainage)

Slit lamp examination preferablePunctal stenosis or nasolacrimal

duct obstruction

Main sign is epiphora

(excessive tears)

Causes watery eye(s)

(Source: Kanski)


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Objective (LOOK FOR)external (conjunctiva)

Slit lamp examination with Fluorescein

preferable

Fluorescein staining

Superficial punctate staining on bulbar

conjunctiva may occur with dry eye

Check for foreign bodyMild redness/injection

Bulbar


eye, trichiasis

Move over scleraLimbal

Examples: foreign body on cornea,

corneal ulcer

Suggests more serious cause

(unreliable sign)

(Source: http://en.wikipedia.org/wiki/Allergic_conjunctivitis)


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Objective (LOOK FOR)external (conjunctiva)

Slit lamp examination preferable

Swelling/oedema

Example: allergic conjunctivitisDischarge

Watery (clear)

Examples: allergic

conjunctivitis

Mucopurulent (yellow, pus-like)Examples: corneal ulcer

(infectious)

(Source: http://en.wikipedia.org/wiki/Allergic_conjunctivitis)


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Objective (LOOK FOR)external (evert lids)

Slit lamp biomicroscopy with

Fluorescein preferable

Check for foreign body under eyelid

Pull down lower lid as well

Papillae (lid roughness)

Stain with fluorescein

Indicates allergic conjunctivitis

(CCLRU grading scales)


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Objective (LOOK FOR)external (cornea)

Slit lamp examination with Fluorescein

preferable

Check for foreign body on cornea

Fluorescein staining

Superficial punctate staining mayoccur with dry eye or allergy to

contact lens solutions

Can reveal corneal abrasion

caused by foreign body or trichiasis

Can stain corneal ulcer

Exposure staining may be caused

by ectropian

Epithelial opacity/stromal infiltrate

Indicates corneal ulcer

(Source: Kanski)


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)internal examination




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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)


Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)Refraction & near add

Refraction

Could carry out pinhole testover current Rx

Could over-refract current Rx

Rules out ametropia if blurred

vision is reported

Otherwise of little diagnostic

value here


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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)

Refraction & near add determination

(refractive)

Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)Tonometry




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Case History

(all systems)

Visual acuity



(binocular)

Pupil responses



(ocular health)

Refraction & near add determination

(refractive)

Tonometry

(ocular health)

Visual fields

(visual)

Objective (LOOK FOR)Visual fields




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Analysisdifferential diagnosis

During subjective and objective

parts of SOAP

Will cover some examples in

tutorials next week


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PlanTreatment/advice


eye, blepharitis, foreign body (on

cornea, under eyelid)

Note:Consider pharmaceutical options

with allergic conjunctivitis and dry

eye

Advice on lid hygiene with

blepharitis

Carefully remove foreign body with

cotton bud (under topical

anaesthesia if necessary)


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PlanReferral (immediate)

Example: corneal ulcer

Note immediacy of :

Corneal ulcer, regardless

of cause (to exclude

bacterial keratitis)


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PlanReferral (same day)

Example: foreign body (oncornea, under eyelid)

Note urgency of:

Foreign body that is

distressing to patient and

cannot be removed


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PlanReferral (urgent1 week)

Examples: persistent allergic

conjunctivitis (>2/52), dry eye (if severe

and patient has rheumatoid arthritis),

unexplained foreign body sensation (withpain, photophobia or blurred vision)

NOTE urgency of :

Allergic conjunctivitis if persists for

over 2 weeksDry eye with rheumatoid arthritis

(suggests hyposecretive dry eye e.g.Sjgrens syndrome)Unexplained foreign body sensationwith pain, photophobia or blurredvision


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PlanReferral (urgent2 weeks)

Examples: ectropion (if evidence ofcorneal exposure), trichiasis (if evidence

of corneal erosion)

NOTE urgency of :

Ectropion & trichiasis if there is

evidence of corneal exposure/erosion(Fluorescein staining)


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PlanReferral (soon1 month)

Examples: trichiasis (no evidence of

corneal erosion), unexplained foreign

body sensation (with out pain,photophobia or blurred vision)

Note urgency of :

Trichiasis where there is no

evidence of corneal exposure (no

Fluorescein staining)

Unexplained foreign bodysensation (with out pain,

photophobia or blurred vision)


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PlanReferral (routineno specified time)

Examples: dry eye (if not severe and there is no

rheumatoid arthritis), blepharitis (if concerned),

ectropion (if patient wants surgery), age-related

nasolacrimal duct obstruction , punctal stenosis,

isolated epiphora, epiphora with recurrent

conjunctivitisNote referral of:

Dry eye that is not severe or without

rheumatoid arthritis

Blepharitis that persists despite lid hygiene

Ectropion if patient wants surgeryEpiphora due to age-related nasolacrimal

duct obstruction or punctal stenosis

Isolated epiphora or epiphoral with recurrent

conjunctivitis


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You should now understand:

How to approach a problem-orientated eye examination on a person presenting with

watery, itchy or gritty eye(s) or, maybe, foreign body sensation

That these symptoms are often the most common but least serious complaints

That most of the required tests relate to external eye examination to investigate an

ocular surface problem

That additional procedures should include slit lamp biomicroscopy with Fluorescein,

eyelid eversion & dry eye tests (TBUT, tear meniscus, Schirmer test, Lissamine green

test)

That unexplained foreign body sensation requires referral (urgent if it occurs with

blurred vision, pain or photophobia)

That referral urgency is raised when there is (1) pain, photophobia or blurred vision

and (2) evidence of corneal exposure; All of these point to a possible corneal ulcer

cpd10 (watery, itchy & gritty eye) (10 sep 10)

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