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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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148
EYELID PROBLEMS
The GP overview
Because of their close proximity to the eye, and their occasional cosmetic eect, eyelid problems
can be disproportionately distressing to the patient. e dierential diagnosis is wide – so the
temptation to treat this presentation as a ‘quickie’ via a brief examination shouldn’t distract from
the need to take a careful history.
Differential diagnosis
COMMON
stye
blepharitis
meibomian cyst
xanthelasma
blocked tear duct
OCCASIONAL
periorbital oedema (e.g. orbital cellulitis, herpes zoster, angio-oedema, nephrotic syndrome,
insect bite)
ectropion
entropion (may be secondary trichiasis)
eczema (seborrhoeic, allergic)
ptosis (congenital, oculomotor nerve palsy, Horner’s syndrome, myasthenia gravis, senile,
myotonic dystrophy)
muscular problems (myokymia, blepharospasm)
RARE
malignant growth (e.g. basal cell carcinoma)
benign growths (e.g. papilloma, haemangioma)
dacrocystitis
alopecia
molluscum contagiosum
lice
https://t.me/med1917
EYELID PROBLEMS 149
Ready reckoner
Stye Blepharitis Meibomian cyst Xanthelasma Blocked tear duct
Painful Ye s No Possible No No
Long history No Possible Possible Ye s Possible
Visible swelling Ye s No Ye s Ye s No
Eye watering No No No No Ye s
Lids itchy No Ye s No No No
Possible investigations
LI KE LY: Lipid prole.
POSSIBLE: Urinalysis, FBC, LFT.
SMALL PRINT: Tests for ptosis, biopsy.
Lipid prole: If xanthelasma, as may indicate hypercholesterolaemia.
Urinalysis: Proteinuria in nephrotic syndrome.
FBC: WCC raised in infective process (e.g. cellulitis).
LFT: Hypoproteinaemia in nephrotic syndrome.
Further tests for ptosis (usually in secondary care) (e.g. CXR [Horner’s], edrophonium test
[myasthenia], blood sugar and brain scan [oculomotor palsy]).
Biopsy – if suspicion of malignancy.
TOP TIPS
A meibomian cyst is oen misdiagnosed – by patient and doctor – as a stye, particularly if
it is infected.
Entropion with secondary trichiasis may be overlooked as a cause of a recurring sore, watering
eye, especially in the elderly.
Myokymia: Recurrent focal twitching of the orbicularis oculi – is harmless but may distress
or alarm the patient.
Many patients with xanthelasma will already have been ‘noted’ and so have had their
cholesterol measured. Enquire about this before wasting resources on further unnecessary
checks.
https://t.me/med1917
150 SYMPTOM SORTER
Orbital cellulitis requires urgent inpatient treatment.
Bilateral ptosis which deteriorates through the day may indicate myasthenia gravis.
New onset of unilateral ptosis requires investigation – possible diagnoses range from diabetes
to malignancy.
Loss of the eyelashes is a poor prognostic sign in alopecia.
Unilateral eyelash loss, with or without apparent blepharitis, may be a sign of an eyelid
tumour.
NOTES:
https://t.me/med1917
151
FLASHES, FLOATERS
AND TRANSIENT
VISUAL DISTURBANCE
The GP overview
is symptom can be very dicult to fathom, not least because patients oen nd it nigh on
impossible to describe exactly what they’ve experienced. Patience and a painstaking approach are
essential – most of the clues are likely to be in the history rather than in the examination. is
section does not cover double vision, gradual loss of vision or persistent sudden loss of vision,
which are dealt with elsewhere.
Differential diagnosis
COMMON
‘normal’ oaters
migraine
posterior vitreous detachment
amaurosis fugax
retinal detachment
OCCASIONAL
temporal arteritis
vasovagals and orthostatic hypotension (commonly cause the symptom but rarely present
with it)
vitreous haemorrhage
medication (e.g. transient blurred vision with anticholinergics, blue tinge to vision with
sildenal)
poorly controlled diabetes
TIA
optic neuritis
https://t.me/med1917
152 SYMPTOM SORTER
RARE
papilloedema
trauma
posterior uveitis
seizures
psychological
Ready reckoner
Normal
oaters
Migraine Posterior vitreous
detachment
Amaurosis
fugax
Retinal
detachment
Sudden onset No Ye s Ye s Ye s Ye s
Blurred vision No Possible No Yes Possible
Eye symptoms resolve in <1 hour
No Ye s Possible Ye s No
Flashing lights No Possible Ye s No Possible
‘Curtain’ effect No Possible No Ye s Possible
Possible investigations
e GP is highly unlikely to initiate any investigations in this situation – apart, perhaps, from a
blood sugar or HbA1c to check for undiagnosed diabetes or an urgent ESR in suspected temporal
arteritis. Otherwise, any investigations required would be arranged by the ophthalmologist or
neurologist aer urgent or routine referral, depending on the clinical picture.
TOP TIPS
It is tempting to ‘bounce’ some of these cases to a local optician for assessment. Resist this
approach – you may delay an important diagnosis and, besides, even a thorough examination
is unlikely to provide anything like as much relevant information as a careful history.
Some patients nd it easier to ‘draw’ their visual disturbance than describe it.
Floaters are a fairly common presentation – one of the key issues to establish is the duration
of the symptom. e longer they have been present, the more you can be reassured that they
are ‘normal ’.
Remember that ocular migraine can occur without the ‘usual’ headache.
https://t.me/med1917
FLASHES, FLOATERS AND TRANSIENT VISUAL DISTURBANCE 153
A sudden onset of a shower of oaters is signicant – especially if accompanied by ashing
lights or blurred vision. Refer urgently to exclude a retinal detachment.
Do not forget temporal arteritis as a cause of transient visual disturbance, especially in
patients aged 50 or more. Treat with high-dose steroids on suspicion of this diagnosis – do
not wait for the results of blood tests.
Remember to check whether a young woman with migrainous visual disturbance is on the
combined contraceptive pill and advise accordingly.
Amaurosis fugax is a form of TIA and should be managed as such – apply your local ‘TIA
pathway’.
NOTES:
https://t.me/med1917
154
GRADUAL LOSS
OF VISION
The GP overview
e four major causes of gradual blindness in the world are: cataract, onchocerciasis, vitamin
A deciency and trachoma. e latter three are very rare in the UK. Cataract occurs in 75% of
over-65 s, but only 20% of 45- to 65-year-olds. Most cases of gradual loss of vision encountered
in primary care arrive via the optician, oen with a letter outlining the problem and suggesting
referral to an ophthalmologist.
Differential diagnosis
COMMON
cataract
chronic glaucoma
diabetic and hypertensive retinopathy
senile macular degeneration
gradual inferior retinal detachment
OCCASIONAL
choroidoretinitis
optic neuritis (in MS)
Paget’s disease of the skull
retinitis pigmentosa
intraorbital or intracranial tumours
RARE
syphilis
cerebromacular degeneration
toxic amblyopia (tobacco, methanol, arsenic, quinine, carbon bisulphide)
choroidal melanoma
Leber’s hereditary optic atrophy
https://t.me/med1917
GRADUAL LOSS OF VISION 155
Ready reckoner
Cataract Glaucoma Retinopathy Macular
degeneration
Retinal
detachment
Unilateral visual loss Possible Possible Possible Possible Ye s
Pigment at macula No No No Ye s No
Exudate + haemorrhage
No No Ye s Yes No
Fundus obscured Ye s No Possible No No
Disc cupped >50%
No Ye s No No No
Possible investigations
e only investigation the GP is likely to perform is a urinalysis and/or blood sugar or HbA1c for
suspected diabetes. If glaucoma is a possibility, and the patient has not already seen the optician,
then optician referral will provide information about elds and pressures. More obscure tests –
such as posterior pole ultrasound and CT scan for retinal, or other, tumours; syphilis serology;
skull x-ray for Paget’s disease; and neurological investigations for MS – are rarely required and
are inevitably arranged in secondary care.
TOP TIPS
Opticians will tend to report cataracts in the elderly routinely. Referral for surgery is only
required if the problem is signicantly impairing the individual’s normal activities.
e presence of a cataract in relatively young patients is unusual and should prompt referral
regardless of visual impairment – there may be a rare underlying metabolic cause.
Remember that signicant glaucoma or other causes of visual loss may render the individual
unt to drive.
e elderly patient with a cataract whose vision is not improved considerably with the
pinhole test probably has macular degeneration too, and so is unlikely to benet much from
cataract extraction.
https://t.me/med1917
156 SYMPTOM SORTER
It can be very dicult to establish in an elderly person whether the problem really has been
gradual in onset or whether the history is more sudden; if in doubt, refer urgently as the cause
may be acute and remediable.
Progressive early morning headache or proptosis with gradual loss of vision suggests a
tumour. Refer urgently.
Gradual or recurrent visual loss or blurring with other intermittent neurological symptoms,
especially in younger patients, suggests the possibility of MS.
NOTES:
https://t.me/med1917
157
ITCHY OR IRRITATING
EYES OR EYELIDS
The GP overview
is is a nuisance symptom which patients present with directly, or via their optician. It can be
very dicult to ascertain whether the problem is arising from the eyelid or the eye itself. Oen,
the symptoms aect both and the causes overlap – which is why they’re considered together here.
Differential diagnosis
COMMON
allergic conjunctivitis (usually hay fever)
infective conjunctivitis
dry eyes
blepharitis
blocked tear duct
OCCASIONAL
ectropion
entropion
eczema of the eyelids
eect of contact lenses or solutions
iatrogenic (oral or local medication)
foreign body (though usually presents with pain and redness)
RARE
pubic lice (can aect eyelashes)
oppy eyelid syndrome (chronic conjunctivitis with lax eyelids in obese, middle-aged men)
sebaceous gland carcinoma
thyroid eye disease
https://t.me/med1917
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