Pick ‘n’ Mix Week 3 March 2023
We are really grateful to Trudie Pestell for sharing Pick ‘n’ Mix: a fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department.
Each week we will bring you some clinical pearls to add to your knowledge and understanding with links to other resources as well as an OSCE of the week.
Presentation
A 55 year old female presents to the ED with a red eye. It came on suddenly and the pain is severe and worsening. She has a headache, nausea, and vomiting and complains of not being able to see as well as usual. On examination, her cornea looks hazy and her globe is hard to palpation
Pathophysiology
Primary closed-angle glaucoma occurs with a reduction in the angle between the iris and the cornea, impairing aqueous humor drainage, and resulting in raised intraocular pressure. The raised pressure ultimately damages the optic nerve and can cause disc changes (cupping and pallor). In secondary closed-angle glaucoma, the reduced angle can be caused by chronic anterior uveitis or lens subluxation.
Precipitants
- Semi-prone positioning
- Screentime in a dark room
- Adrenergic medications – adrenaline given in anaphylaxis
- Antimuscarinic medicatons (such as tricyclic antidepressants)
Risk Factors
- Increasing age
- Female
- Asian background
- Family history
- Hyperopia (farsightedness)
Investigations – Early suspicion is key – this is a sight-threatening diagnosis
- Gonioscopy
- Slit lamp examination
Management
- Lie the patient face up, and flat (no pillows)
- Symptomatic relief – analgesia and antiemetics
- Pilocarpine (a cholinergic agonist)
- Azetozolamide (reducing the production of aqueous humor)
- Definitive management – Laser iridotomy
The case of the breathless traveller
The beginning:
A 42-year-old lady comes to the Emergency Department feeling generally unwell and lethargic. She has recently returned from India and has developed a new cough and fever. Sometimes she coughs so much, blood comes up. As part of your workup, you perform a CXR
OSCE of the Week – Ophthalmological Examination
Introduction
“Hello, my name is Phil. I am one of the medical students”.
“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”
“Are you comfortable? Do you need any pain relief or a drink?”
“I have been asked to examine your eyes. This will involve me looking at them directly and with a light source; testing your vision; eye movements, and reflexes. Is that ok with you?”
“Would you like a chaperone present?”
“I will talk out loud as we go”
“If at any time you want me to stop or you are in pain, let me know”
Brief history
“Can you briefly tell me what the problem is?
“Any trauma or injury?”
“Do you wear glasses or contact lenses normally? Have you got them with you?”
General inspection
Face the patient
“In terms of general inspection I am looking at the…”
- External eye appearances: ptosis; proptosis; squint; head tilt; pupil symmetry
- Lids; lashes; lacrimal gland and duct: swelling of lids; position (ectropion/entropion); blepharitis; blepharospasm; follicles; crusting/pus
- Cornea; conjunctiva; sclera: Cornea (white/hazy); sclera (injection – diffuse/local)
- Foreign bodies: Examiner: “would you like me to evert eyelids, fluorescein and assess using the slit lamp?”
Pupils
- Appearance: size; shape; symmetry
- Reflexes
- Direct
- Consensual
- Swinging light test (RAPD – Marcus Gunn pupil)
- Accommodation: please focus on something in the background; now looking at my finger (pupils constrict on focusing from far to near objects)
- Squint: cover/uncover test
Visual acuity
“If you normally wear glasses please put them on. If haven’t got them with you I will use a pin hole.” (If vision improves this suggests a refractive error)
“I will examine each eye in turn…”
Far vision
- “I will use this Snellen chart to assess acuity
- Please stand here at a distance of six metres from the chart
- Close one eye, read lowest line possible, then change side
Visual acuity(V/A) = 6/number of line achieved
Near vision
Examiner: would you like me to assess near vision by asking the patient to read a sentence from a book?
Colour vision
Examiner: would you like me to assess colour vision using the Ishihara plates?
Visual fields
“Please cover one eye. I will cover the opposite and we will look at each in turn…”
“I will sit opposite you. Please look at my nose, I will bring my finger in from the side, say yes when you see my finger and if you see it disappear at any time (assess 6 quadrants)…”
Examiner: “would you like me to formally assess blind spot (red hat pin) or for neglect?”
Eye movements
“Follow my finger with your eyes keeping your head still. Tell me if you get any pain or double vision.”
Examiner: “I am looking for nystagmus and ptosis.”
Fundoscopy
“I would do this in a dark room, having dilated the pupils with a short acting drop like 1% tropicamide. I will have informed the patient that they cannot drive until their vision is back to normal.”
I am examining the:
- Red reflex
- Retina (start lateral, find a vessel and move in), paying particular attention to:
- Optic disc (normal cup/disc ratio 0.3)
- Retinal vessels (tortuous; nipping; neovascularisation; haemorrhage)
- Macula (“Please look into my light” -cherry red = CRAO, drusen = mac degen
Close
“Thank you. That is the end of the examination”
“To complete my examination I would like to…”
- perform a slit lamp exam,
- check intraoccular pressures,
- a full cranial nerve examination,
- assess for risk factors for GCA and investigate as needed
“Does that sound reasonable to you? Do you have any questions or concerns?
Additional resources
- Examination of the eyes and vision
- Fundoscopy
- NICE: Eye conditions overview
- Geeky medics (eyelid disorders; red eye: painless and painful; acute angle closure glaucoma; retinal detachment; painless sudden visual loss; orbital and periorbital cellulitis; eye drops
- Also see cranial nerve additional resources above