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Consultant Ophthalmologist, Cataract & Refractive Surgeon
BMedSci BM BS MRCS MRCSEd MRCOpth FRCOphth MMedLaw PgD Cataract & Refractive Surgery

Eye Disorders and How to Treat them

The information in the following links is adapted from my text entitled "Ophthalmology in Primary Care" published by The Royal College of General Practitioners and available for purchase here.

This section is designed to give you an understanding of the various conditions you may see and the vast number of pathological diagnoses you may get back from the hospital.

This is a list of each condition that will give you guidance as to:

  • what's going on?,
  • what you'll find if you examine the patient,
  • what to do if you've diagnosed it,
  • a rough guide as to what the hospital will do with the patient after referral,
  • what you need to do with your patient,
  • what to tell your patient and
  • potential problems that may arise, and how to deal with them.

It should be emphasised that these are rough guidelines and each patient will have to be managed according to the specific clinical scenario.

You can always ask generic questions about any of these disorders by email.

If a condition you want to know about is not here let us know and we will add a section on it shortly.

Amaurosis fugax

What's going on?

This is transient ischaemic attack (TIA) of the retinal circulation. An embolus has lodged in the central retinal circulation and caused ischaemia of the retina. The embolus either dislodges or is lysed, and blood flow is restored. Classically, patients describe the sudden, painless onset of complete visual loss in one eye. Often they describe a black or grey curtain falling or rising over their vision.

If I examine the patient, what will I find?

By definition after the resolution of the episode there should be no residual visual defect. There may be a carotid bruit on auscultation (although some clinicians believe this is a completely worthless sign) or the patient may have atrial fibrillation.

What if I've diagnosed it?

If the diagnosis is clear-cut and the vision is completely restored with no evidence of any visual field defect, then referral to the eye service is not required.

If the diagnosis is in doubt the patient should be referred soon via letter.

If there are multiple episodes, the possibility of GCA should be considered and an ESR/CRP obtained, even in the absence of GCA symptoms. If GCA symptoms are present, urgent assessment of inflammatory indices and urgent referral if the results are positive is required.

Any predisposing factors should be addressed as described above.

If you have access to a TIA fast-track clinic, then refer according to local criteria.

What will the hospital do?

Carotid Dopplers and/or a cardiac echo will be organised. If carotid Dopplers indicate a significant stenosis, referral may be made directly to a vascular surgeon. Inflammatory indices should be checked in case the patient has occult asymptomatic GCA.

What do I need to do?

These patients are at risk of further embolic phenomena, which could result in a permanent occlusion (central retinal artery occlusion) or even a CVA. Cardiovascular risk factors should be addressed and carotid Dopplers or cardiac echo should be arranged to ensure there is no carotid or cardiac source of embolus. Antiplatelet medication should be considered as a prophylactic measure.

What to tell the patient

They have had a mini-stroke and are at risk of further ocular or cerebral embolic events.

Amblyopia

What's going on?

This is what is known as 'lazy eye'. The brain relies on visual input in the first five years of life to lay down the visual pathways for normal vision. If the brain is deprived of normal focused vision in one or both eyes in early life, it ignores that eye and vision does not develop to its full potential. This is irreversible after approximately five to eight years of age (depending on type), but if the problem is alleviated, vision may be restored to its full potential.

Many adults have a long-standing lazy eye, in which vision may vary from 6/9 to counting fingers.

If I examine the patient what will I find?

By definition the findings will be normal. However, the patient may have a squint.

What if I've diagnosed it?

Amblyopia is a diagnosis of exclusion. Adults with unexplained visual loss from childhood with no evidence of any pathology will have amblyopia. If the patient is not certain that the vision has been poor from childhood or they feel that there has been a further deterioration in vision, they should be assessed by the ophthalmology service routinely. When there is a concern about a child's vision in one or both eyes they should be referred soon via letter for formal assessment and potential treatment.

What will the hospital do?

Organic pathology will be excluded and a full orthoptic assessment carried out to look for a squint. In children, spectacles may be prescribed, and occlusion (patching) treatment may be started on a full- or part-time basis to encourage use of the lazy eye. Subsequently, squint surgery may be considered.

What do I need to do?

If the child is prescribed spectacles or patching, it is vital that the parents are advised about the importance of compliance. Saying that it is difficult to make an uncooperative child wear spectacles or a patch is an understatement.

Problems that may arise, and how to deal with them

Patching treatment can be difficult because children don't like it, and lack of compliance can hamper progress. It is important to emphasise the window of opportunity in childhood to restore vision, and the need for regular follow-up.

Angle recession

What's going on?

A blunt injury to the eye has caused a pressure wave to rip open the drainage angle of the eye. The rip heals, leaving scarring that impedes aqueous outflow. If the extent of the recession is great, the patient may develop glaucoma months or years later.

If I examine the patient what will I find?

You may see signs of the previous injury, but equally you may see no obvious abnormality.

What will the hospital do?

If the recession involves most of the angle, then the patient may be followed up at regular intervals to detect the onset of glaucoma. If the injury is minimal, the patient is usually discharged but advised to see their optician for regular pressure checks.

What do I need to do?

If the patient is not followed up at hospital, they should be examined regularly by an optician for the onset of glaucoma.

What to tell the patient

They have sustained damage that increases their risk of developing glaucoma.

Anterior Ischaemic Optic Neuropathy

What's going on?

The blood supply to optic nerve has been compromised, resulting in loss of vision. The cause is either a microinfarct (non-arteritic anterior ischaemic optic neuropathy (NAION) or an inflammatory process, usually secondary to giant cell arteritis (arteritic anterior ischaemic neuropathy). The patient may lose their whole field of vision or develop a pattern of visual loss, such as an altitudinal defect when only the upper or lower portion of the visual field is lost.

If I examine the patient what will I find?

The vision will be reduced. They may have an upper or lower altitudinal visual field defect. The disc will be swollen. There will be a relative afferent papillary defect.

What if I've diagnosed it?

Giant cell arteritis needs excluding. Refer urgently.

What will the hospital do?

If there is a suspicion of GCA, the patient will undergo a temporal artery biopsy to exclude or confirm the diagnosis. Inflammatory indices will be assessed. If it is a non-arteritic process, there is no possible intervention and a conservative approach is taken in the hope of spontaneous recovery.

What do I need to do?

If the process is arteritic, the patient will be on long-term steroids. Consider osteoporosis prophylaxis and gastric acid protection.

If the process is non-arteritic, then assessment of cardiovascular and cerebrovascular risk factors is prudent. Consider antiplatelet treatment as a prophylactic measure if not contraindicated.

What to tell the patient

The prognosis is much better for the non-arteritic process. Visual recovery is extremely unlikely in the arteritic process.

Problems that may arise, and how to deal with them

Despite steroid treatment, the vision may deteriorate further due to the on-going inflammatory process. If vision deteriorates or the patient has a recurrence of GCA symptoms, their inflammatory indices should be measured urgently and the steroid dose increased.

Argyll Robertson Pupil

What’s going on?

The patient has a pupil abnormality classically related to neurosyphilis. The cerebral centres responsible for stimulating pupil constriction in response to a bright light and to looking at a near object (accommodation) are separate. Lesions that block the light reflex may spare the accommodation reflex. Such lesions result in an Argyll Robertson pupil.

If I examine the patient what will I find?

The pupils will not react to light, but when the patient is asked to read the pupils will miose (constrict). This is called light-near dissociation.

What if I’ve diagnosed it?

Refer soon via letter.

What will the hospital do?

Screen for leutic disease. Neuro-imaging may be indicated to exclude a space-occupying lesion.