Final Year Series: Ophthalmology 101- Eye history and red flags for UKMLA

Ophthalmology 101- Eye history and red flags for UKMLA

“Doctor, my eye is red and painful” – this article will provide tips and tricks on taking an ocular history along with common pitfalls. Ophthalmology 101 will cover the foundational basics which we will build on over the next 4 sessions (and corresponding articles) covering high-yield ophthalmology content.

Prepare for OSCE and UKMLA ophthalmology content. Catch up on our 1hr session covering ophthalmology basics (anatomy, eye history, red flag symptoms).

This session is part of the Mind the Bleep Final year series, make sure to catch up with on the session recording and slides & check out our other sessions!

Learning Objectives
  1. Recall basic eye anatomy
  2. Take a basic ophthalmological history
  3. Identify red flags
  4. Consider differentials for a red eye
Part 1: Eye Anatomy
  1. Form – ciliary body pumps aqueous, vitreous is a scaffold, sclera forms its casing
  2. Position – extraocular muscles, ligaments, orbit
  3. Sustenance – ophthalmic artery, choroid, tear film
  4. Hydration – lids, lacrimal gland, conj
  5. Light – tear film, cornea, lens refract; iris gatekeeps amount; retina
    receives
  6. Sight – retina, optic nerve, occipital lobe
  7. Movement – extraocular muscles, nerve supply
image 6 2

Copyright: This image belongs to Oscar Wylee. 

Part 2: Red Flags, Red Eye, and History Taking
What can cause it to go wrong?
  • Surgical sieve
    o Infective – conjunctivitis, keratitis
    o Autoimmune – allergy, uveitis, scleritis
    o Vascular – CRAO, CRVO
    o Trauma – retrobulbar haemorrhage, blowout fracture, globe rupture
    o Neoplastic – SOLs causing papilloedema, nerve palsies, horner’s
NICE Red Flags – Same day referral to Ophalmology
  1. Reduced vision or visual acuity
  2. Deep pain in the eye or tenderness on palpation of the globe
  3. Photophobia
  4. Unequal pupil or abnormal pupil reactions
  5. High velocity or chemical injury
  6. Contact lens use
  7. Fluorescein staining
  8. Neonatal conjunctivitis – conjunctivitis in the infant in the first 28 days of life
Painful red eye SBAs

A 36F contact lens wearer has come in today with a very painful, photophobic and red left eye. Vision is down to 6/12. On slit lamp exam you notice conjunctival injection, and a circular epithelial defect staining with fluorescein measuring 2mm2.
What is the most likely diagnosis?

A) Anterior uveitis
B) Scleritis
C) Conjunctivitis
D) Microbial keratitis

ANSWER: D

A 25M who has a chronic history of backpain has presented with a very painful, injected, and photophobic right eye. He describes the pain as a dull throb. On examination VA is 6/36 and the view on slit lamp is hazy but you can see grade 2 cells in the anterior chamber, keratotic precipitates, and posterior synechiae.
What is the most likely diagnosis?

A) Anterior uveitis
B) Scleritis
C) Conjunctivitis
D) Microbial keratitis

ANSWER: A

A 42F contact lens wearer has come in today with a very painful, photophobic, and red left eye. Vision is down to 6/60. On slit lamp exam you notice conjunctival injection, and a large central epithelial defect staining with fluorescein measuring 4mm by 5mm. You note that there is a hypopyon.
What should be the next step in management?

A) Start PO antibiotics
B) Direct to opticians
C) Start chloramphenicol ointment
D) Same day referral to ophthalmology

ANSWER: D

History Taking and Examination

Take your history as you would for a normal history taking station
o Be logical in your questions and differentials
o Main presenting feature and duration
▪ Systemic symptoms – Pyrexia? Vomiting? Headache?
o One eye or both?

  • Key questions:
    o Why have they come in
    â–ª And they will tell you: Vision blurry/Pain/Painless/Itchy
    o What where they doing
    o How long has it been going on for

In terms of clinical skills be comfortable with (UKMLA)
o Direct ophthalmoscope
â–ª Be aware of how a normal fundus looks like
â–ª Papilloedema
▪ Glaucomatous disc – pale, C:D
â–ª CRVO stormy sunset
â–ª CRAO cherry red spot
â–ª Diabetic lasers
o Cranial nerve exams
▪ 2 – acuity, fields, ishihara, reflexes, direct ophthalmoscope
▪ 3, 4, 6 – ocular motility

True Eye Emergencies that need Ophthalmology input

time = sight, and earlier treatment = better outcomes

  1. Acute angle closure
  2. Ocular GCA
  3. Orbital cellulitis
  4. Retrobulbar Haemorrhage
  5. Globe Rupture

References:

Link to full session slides: https://app.medall.org/contents/sd-final-year-series-ophthalmology-101-eye-history-and-red-flags-for-ukmla

Link to full session recording:

Give us feedback: https://app.medall.org/feedback/feedback-flow?keyword=7cbf225c08cfbf8da1da6399&organisation=mind-the-bleep

  1. https://www.oscarwylee.com.au/glasses/eye/anatomy
  2. https://cks.nice.org.uk/topics/red-eye/management/management-of-red-eye/
  3. https://www.northoftyneapc.nhs.uk/wp-content/uploads/2023/01/Ophthalmology-Referral-Guidelines-January-2023.pdf

Authors: Dr Maiar Elhariry & Dr Sze Jing Chuah

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