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TITLE: Presentation 5 Joe Abbott

DATE: 19th February 2017

NUMBER OF SPEAKERS: 1 Numbers Speakers

TRANSCRIPT STYLE: Intelligent Verbatim

FILE DURATION: 30 Minutes 12 Sec

TRANSCRIPTIONIST: Marg Searing

SPEAKERS

JA: Joe Abbott

Audience

GP Eye Health Network: Paediatric Ophthalmology, Mr J Abbott

JW: I’ve been a Consultant at the children’s hospital, soon to be Children’s Women’s Hospital, for five years and I’m gonna talk to you about paediatric ophthalmology. There’ll be some opportunity for me to ask you questions and you to ask me questions.

So, this was the title I was given: common eye conditions, what they are, what GPs need to know, paediatric ophthalmology.

So, this is what I’m gonna talk to you about. What do paediatric ophthalmologists do? I think that’s quite useful cos it, sort of gives you a menu of the sort of serious stuff that you need to keep an eye out for that needs referral.

How to assess an eye problem in a child? So, this is a very broad talk really, cos a lot of the lessons for paediatric ophthalmology are applicable to the whole of ophthalmology. So, if I’m repeating anything you’ve heard already, please just get me to skip on. They’ve got plenty that I can cover.

Conditions which require referral. So, these, I’ve stratified these according, to their urgency and their seriousness. So, emergency problems, urgent problems and routine problems.

Conditions which I’m very grateful to you guys for managing in primary care and some tips around that. And some sort of danger scenarios and pitfalls.

So, that’s what we’re gonna look at. So, what does a paediatric ophthalmologist do? Well, more than my adult colleagues. I can say that, cos I don’t think there are any in the room. We kind of consider the whole patient [laughing] and so, we can consider the whole child, but particularly the fact that the eye is part of the nervous system. And obviously, our area then is to focus in on the bits of the eye that can go wrong in kids.

So, forgive me for the sort of selfevident, anatomical drawings, but selfevident labels. But I thought you might need that cos that’s my Sankey diagram. [laughing]. But these are the bits that can go wrong. And sort of a whistle stop tour of the serious stuff that we do at the Children’s Hospital. Retinopathy of prematurity. When the lens is opaque. Paediatric cataracts. Ptosis, which his actually, quite a serious problem if it happens during visual development and can need surgical correction. Iritis. Uveitis. Glaucoma. Opaque corneas, corneal problems of one sort or another. Mentioned glaucoma already. Retinoblastoma, we’re one of the two national services for retinoblastoma. Rarely, retinal detachments. Optic nerve problems of a whole variety of different sorts and perhaps one of the most important things is papilloedema. That’s … and I’m gonna go in to that in some detail about what that looks like and what can mimic that. And the sort of bread and butter stuff about straightening eyes that are not straight, so, squint surgery.

And, but as I mentioned, we consider the child in the context of their life. So, we’re liaising with schools, families, primary care, you guys, optometry, teachers, sensory support people of various, different sorts, low vision services. So, our role is both in the hospital but we’re kind of looking outwards on behalf of the child quite a bit.

So, how to assess an eye problem. So, this is whizzing through how to assess an eye, particularly, in a child. So, you gather the clinical information. You either make, a decision to refer and then you decide. I think it’s helpful to be mindful of the urgency. And I’ve put in the talk, appropriate contact numbers for our hospital and ways to get hold of us according, to which of those urgencies you decide applies. Or you might decide, right I know what this is, I’m gonna make a diagnosis and I’m gonna manage this.

So, how do you acquire the clinical information? Well this is a sort of silly way of remembering this, but this is a vexed man from Mr Messerschmidt and if he was a constable, he’d be PC VEXd. So, PC VEXd is a way to remember to gather the clinical information.

So, presenting complaint, it’s pretty, self-evident. Vision has … so on referrals that we receive, some of these bits are sometimes missing. Sometimes you can’t gather this information cos the … if it’s a child it’s not always possible. But these are really, important measures of vision and visual field, in particular.

Pupils in particular will get all of us out of trouble on occasion, to spot dangerous pathology. Eye movements, limitations, what the eyes are doing in the primary position. I’m gonna show you some pictures about that. And, when you’re examining the eye, it’s useful to think anatomically from front to back, so, lids, cornea, anterior chamber, lens, retina. And I appreciate, and it’s impossible to see all, of these things in all children but to have that sort of mental structure in mind is helpful. And really, importantly, for paediatric ophthalmology as distinct from other walks of ophthalmology, what’s happening in terms of developmental progress and that can be helpful thing as well if there’s a neurodegenerative sort of context then that completely changes the type of pathology we might be thinking about.

So, visual acuity, what does that mean? This is something, you know, see, got wrong quite frequently from colleagues in the hospital and from primary care. So, visual acuity, how … it’s your ability to distinguish two spots in space. So, on a chart, a big spot gives you a big thing. Two spots a distance apart give a big angle at the eye. And a small thing, a small letter, give a small angle at the eye. And that’s all you’re measuring with visual acuity.

So, people get confused with this, 6/6 or 20/20 terminology. If you think of it as a fraction, 66/66, 20/20 is 100% and worse vision where you can only see a shape 10 times bigger is 10% of the vision. So, forgive me for going through that but I think that’s often quite a helpful little reminder. And when you’re testing vision, children and adults, remember to ask: do they wear glasses. If they don’t wear glasses to look through a pinhole can correct for the equivalent of glasses. And really, importantly, what’s the vision with each eye, otherwise you’ll miss uniocular pathology. So, simple stuff, picks up really, important information.

How do you assess visual fields? And actually, you can do this in really, tiny kids. As, long as they’re old enough to play with you, you can get some idea of visual fields. So, a few very simple questions. Get them to look at your face. Are there any bits of the face missing? So, if they’ve got … you know, we’re talking about rarities and serious stuff. But if there’s a homonymous hemianopia and they’re missing the right half of their visual field with both eyes. They might tell you that half of the face they can’t see when they’re looking at your nose. You’ll have seen this probably with stroke patients more often than children, actually.

So, cortical field loss. Look at me and point at which hand is moving. So, this is a quick way of testing the visual field. So, you get them to fixate with you and you can identify a hemianopia by waving one hand or the other.

And more subtle stuff is, cover one eye, get the patient to look back at you and you can test their different quadrants. And again, they are very important, cos that only by doing this would you pick up a bitemporal hemianopia. Something that points to a pathology around the pituitary. So, we’ll revisit this during the talk but it’s really, important.

Has anybody else gone through this sort of stuff this morning? Do you want me to go through the examination sort of things? Okay, so, RAPD, this should play, he says.

FS1: Okay, if you go back and click on [unclear 00:07:51], just if you look behind your back and see there’s an arrow on the slide there’s a … you move the thin pointer.

JA: Yeah.

FS2: … to the [unclear 00:07:58] …

FS3: Look at the main slide.

FS2: … looking at the main slide on the screen.

JA:Yeah, right. So, relative afferent pupil defect, we’re looking for here. So, this arrow represents the light. The two pupils are doing the same thing. So, when you shine the light on, the pupils constrict. And you get that slight relaxation afterwards which can … it’s called a hippus which can confuse people. But that’s a normal … a video of a normal situation. You turn the lights off, the pupils get bigger. You put the light on the eye and both constrict.

So, what we’re looking for with an RAPD is when there is a problem between the eye and the brain. So, in a second the video will mimic that. And so, here when you shine the light on the left eye, hang on a minute, the eye with the problem will dilate. You didn’t get much chance to see that. But let’s see if I can get that back.

So, right towards the end of the video there, when the light comes across to the left eye, the pupil dilates. So, that means that there’s less signal going through that left eye to the brain and then that’s a really, important sign to tell you that there is an objective problem with the vision. So, you’re not relying on subjective responses. So, the light goes across the left eye and the pupil dilates. And that there, that’s the key thing that you’re looking for with a relative afferent pupil defect.

So, it’s a really, useful sign, cos kids, like all of us try and kid people sometimes. And to have an objective test of vision rather than a subjective test is really, useful and quite a simple thing to do.

So, ocular movements. So, I just wanna show you this cos it’s where this is the light bounces off the cornea, gives you an important clue as to the alignment of the eye. So, any suggestions as to what’s going wrong here? If you look, it’s subtle but where … if you look at where the light is, the corneal reflex, it’s different on the two eyes. So, have we got an esotropia, are the eyes pointing in or have we got an exotropia. So, popular votes are dangerous things, aren’t they, these days, but [laughing].

So, who votes for esotropia? Who thinks this is an esotropia, eyes are pointing in? So, the light reflex here is slightly further to the outside of the cornea. So, no one votes for esotropia? A few votes for esotropia. So, who thinks it’s an exotropia and the eyes are pointing out? Even less votes [laughing]. So, yeah, you’re quite right. So, it’s a subtle thing. And, so, look in the primary position. That can often give you the clue. And then when you actually, get the patient to move their eyes around, it becomes obvious sometimes.

So, this patient, the left eye won’t abduct. There’s sixth nerve palsy. So, that’s a very different situation to this situation, where again, you’ve got an esotropia but the angle between the two eyes stays the same wherever this child is looking. So, as opposed to this patient who, when they looked to this way, the eyes are both pointing at the same thing. When they look this way, in this picture, there’s a big difference between the … so that’s call incomitant and that’s a concomitant squint. So, concomitant means the angle’s always the same, incomitant means the angle changes. This is worrying cos this could be … this is much more likely to be a neurological problem. This is much less worrying and this is what you see in common childhood squints.

So, concomitance and incomitance, whether the angle’s changing between the eyes depending on where patients look.

So, the other bits of the examination. What does the surface look like? Fluorescein, I don’t know how many of you have access to Fluorescein on a regular basis? Good, so really, useful to reveal corneal problems. It sticks to breaks in the epithelium of the cornea if you shine your blue light on it.

So, this is a large epithelial defect. This is what you see if there’s something stuck underneath the eyelid. It’s like a dry … it’s like a windscreen wiper scratching at the windshield. So, if you see that, you know that there’s something hidden underneath the eyelid. And you could have a go at removing it with a cotton bud and inverting the lid.

This is a severe chemical injury. So, I only mention … put this in because chemical injuries are a genuine emergency problem, as I’m sure you know. And need irrigating right then and there. And this is a very serious one. If you see this as well, this is a bad sign. This means that the chemical injury has extended to the conjunctiva and these … this bit of the conjunctiva nourishes the cornea. So, this cornea is gonna really struggle to heal. And very serious injury could well be blinding.

Other, I mean, these are obviously, serious problems. But these are things that you might see on the ocular surface. Traumatic injuries that to be able to describe this, this is a corneal laceration and the iris prolapsing out and a cataract.

So, ophthalmoscopy tips. Tweed is optional. You don’t have to wear tweed [laughing] and you don’t have to have a beard. [laughing] It’s not a very paediatric sort of slide this, is it? But for kids, if you’ve got a little baby, if they’re fed and examining them, you’ll know these tricks I suspect. But colleagues in the adult ophthalmology world forget this, that if a baby’s, got a full tum, then they’ll sleep through a lot of things and you can get a really, good look at their eyes. And that can be a useful tip. So, in clinic quite a frequently, if a baby is of that age, between sort of, well birth and about two, perhaps that’s not right. Perhaps birth and a year of age and if they will go to sleep, we’ll give them the chance to do that and have another go at looking at their eyes. And it can often avoid a trip to theatre.