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BLEPHARITIS

Community Services

Diagnosis

• Symptoms of blepharitis are often intermittent and typically bilateral.

  • Sore eyelids and gritty eyes

  • Dry eye symptoms – blurred vision, contact lens intolerance

• Signs of blepharitis include:

  • Swollen eyelids, inflamed lid margins and inflamed conjunctiva (common complication)

  • Altered eyelash appearance

  • Eyelid surfaces may be scaly, oily or greasy

  • Styes and chazalions are much more common in people with blepharitis

• Visual acuity should be normal, although dry eyes may cause intermittent blurring

• Infection is suggested by ulceration of the anterior lid, or eyelids sticking together (particularly in the morning)

• Swabs for culture and sensitivity are not routinely indicated

Management

• Advise eyelid hygiene twice daily until symptoms resolve and then once daily indefinitely

  • Gently press on the eyelids with a cloth soaked in very warm water for 5-10 minutes

  • Massage and express meibomiam gland contents when there is posterior blepharitis

  • Cleanse lid margins using any of the following – sodium bicarbonate: a teaspoonful in a cup of boiled water; baby shampoo diluted with warm water, or commercial eyelid scrubs (not available on FP10)

• Treat underlying conditions that may be causing or exacerbating blepharitis

• Artificial tears are recommended for people with dry eyes or an abnormal tear film

  • Choice of formulation should generally be guided by individual preference. Hypromellose 0.3% eye drops are the cheapest and most commonly used formulation in the UK

  • Initially use artificial tears as required, at up to 30-minute intervals if symptoms are severe. Decrease the frequency as symptoms improve

  • Use preservative-free drops if more than six applications per day are necessary or if the person uses soft contact lenses

  • Consider prescribing a paraffin eye ointment at bedtime to provide prolonged lubrication

• Contact lenses must not be worn during any eye infection and when eye drops or ointment are being used

• Avoid the use of eye make up

Where there is marked infection:

• Generally prescribe a topical antibiotic and continue for 1 month after the inflammation has settled:

  • Chloramphenicol ointment applied to the lid margins with a finger or cotton bud (after attending to lid hygiene or just at night) is recommended

  • Fusidic acid eye drops are an alternative

• Prescribe an oral antibiotic for recalcitrant staphylococcal blepharitis, severe secondary infection of the meibomiam glands, and local cellulitis

  • Flucloxacillin is recommended first-line

  • Erythromycin or azithromycin is recommended if penicillin is contraindicated

Referral to Secondary Care Services

• Admit urgently if orbital cellulitis is suspected (person is systemically unwell, tender sinuses, restriction of eye movements).

• Refer in the following instances:

  • To exclude malignancy if there is:

    • Persistent localized disease or resistance to treatment

    • Marked eyelid asymmetry

  • If there is evidence of corneal disease

  • If vision deteriorates

  • If there is moderate or severe pain

  • If the diagnosis is uncertain

  • Associated disease, for example Sjögren's syndrome or eyelid deformities, requires specialist management.

References

CKS (Prodigy guidance): Blepharitis
http://www.cks.library.nhs.uk/blepharitis/in_depth/management_issues

Quick reference guides:

Blepharitis: non infected
http://www.cks.library.nhs.uk/qrg/blepharitis_non_infected.pdf

Blepharitis: infected
http://www.cks.library.nhs.uk/qrg/blepharitis_infected.pdf

CATARACT (ADULTS)

General indications for referral for cataract surgery can be found on the North Yorkshire view of the Map of Medicine. See instructions for accessing the Map of Medicine.

In addition, the PCT has commissioned the following referral pathway:

Referral to Secondary Care Services

Simple cataracts (i.e. prime (sole) pathology)

All referrals by Optometrists should be made via the Choice Office following assessment and completion of the Cataract Scoring Tool (see Direct Cataract Referral form) The threshold for referral is a score of 7 and above.

The referral form should be forwarded to:

• NHS North Yorkshire and York, Choice Office, The Hamlet, Hornbeam Park, Harrogate, HG2 8RE.

The Choice Office will ensure the referral meets the threshold and will forward the referral to secondary care within 24 hours. This process will ensure consistency of referrals, enable clinical audit and ensure that, in line with the choice agenda, a choice of secondary provider will be offered to the patient.

Patients who do not meet the threshold should be referred to the PCT’s Individual Funding Request Panel (NHS network connection required) for consideration of exceptional circumstances.

Please contact Lisa Barker, Pathway Implementation and Choice Manager, with any queries on 01423 876429.

Complex cataracts (i.e. significant co-morbidities)

Where the referral threshold is not met, referral may be made by the patient’s GP to secondary care. Patients seen by Optometrists should be referred to the GP with a recommendation to refer to secondary care.

Where the referral threshold is met, referral should be made by the Optometrist through the patient’s GP accompanied by a letter of recommendation.

Second eye surgery

Second eye surgery will be decided in the ophthalmology clinic either at the first appointment (the patient will then be booked for sequenced surgery) or at follow up after first eye surgery. Medical indications for second eye surgery (eg glaucoma, diabetes, anisometropia) should be recorded in the patient letter in case evidence is required for validation purposes. In other cases second eye surgery will be allowed if the patient is symptomatic and there is visually significant cataract.

Source: Yorkshire and the Humber Strategic Health Authority threshold for referral of cataract to secondary care, and local consultation.

BENIGN LID LESIONS

MEIBOMIAN CYST / CHALAZION

This is a retention cyst of the Meibomian gland. It may become infected or may develop into a sterile chronic granuloma in which case it is called a Meibomian cyst or Chalazion.

Community Services

Diagnosis

A chalazion presents as a firm, painless lump in the lid which gradually enlarges. Initially, it may resemble a stye but lacks acute inflammatory signs. The majority point towards the conjunctival surface which may be slightly reddened or elevated. Symptoms (other than cosmetic concerns) are uncommon. Occasionally an upper lid meibomian cyst can press on the cornea and cause astigmatism.

A third of cases will resolve spontaneously and virtually all will resolve within two years.

Management

• Conservative management with eyelid hygiene (see Blepharitis section) and topical mild steroid drops

• If infection present:

  • Acute therapy with oral tetracycline (e.g. doxycycline 100 mg qds for 10 days)

  • Chronic therapy with low-dose oral tetracycline frequently prevents recurrence.  If tetracycline cannot be used, then metronidazole has been used in a similar fashion. 

  • Topical antibiotics e.g. chloramphenicol ointment or fusidic acid eye drops 

• Small, inconspicuous, asymptomatic chalazia may be ignored.

Referral to Secondary Care Services

Referral of patients with meibomian cysts or chalazia which are symptomatic (eg, infection resistant to treatment, astigmatism, rosacea or sebaceous dysfunction), or which have not resolved spontaneously within two years, may be made to the PCT's Individual Funding Request Panel (NHS network connection required).

References

Emedicine
http://www.emedicine.com/oph/topic243.htm

GP notebook
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-234487777

OCULOPLASTIC EYE PROBLEMS (LACRIMAL SAC/NASOLACRIMAL DUCT OBSTRUCTION, ECTROPION, PTOSIS and ENTROPION)

Lacrimal sac/Nasolacrimal duct Obstruction

Background

Watery Eyes can be due to:

i) excess tear production (hyper-lacrimation - rare)

ii) disturbed ocular surface tear flow (lid malposition/blepharitis etc))

iii) compromised outflow

Outflow Compromise

Caused by:

• punctal phimosis or lid malposition

• canalicular stenosis and obstruction

• naso-lacrimal duct blockage (congenital or acquired) or nasolacrimal duct obstruction, the commonest cause of epiphora in adults.

Can cause epiphora (overflow of tears onto the cheek)

Epiphora in Children

Symptomatic NLDO occurs in 5-6% of infants however there is a high spontaneous rate of remission (60-90%) in the first year of life.

Diagnosis in children:

A sticky, watery eye with reflux into the conjunctiva on pressure over the lacrimal sac confirms the diagnosis.

Other diagnostic measures (conducted in secondary care) include probing or dacryoscytography (DCG) and these may be combined with treatment under general anaesthesia. These measures should be delayed until 10 – 12 months of age. Parents can be instructed to undertake lacrimal sac massage during the intervening period. Earlier probing is only justified if there is severe recurrent infection. Alternatively bicanalicular silicone incubation with Crawford or Ritleng tubes can be carried out with claimed success rate of 88%.

Epiphora in Adults

Causes of disturbed ocular surface tear flow such as lid malposition or ocular surface irritation (reflex watering, dry eye, blepharitis) should be excluded first. Identification of the site of the obstruction causing epiphora is most important.

Diagnosis:

Investigations: Identification of the site of blockage requires one or more of the following tests:

i) Dye tests (Secondary Care)

ii) Syringing and Probing (Secondary Care)

iii) Macrodacryocystography (MDCG) and Scintigraphy (Secondary Care)

iv) nasal Endoscopy (Secondary Care)

Primary Care Treatment:

Conservative management comprises:

• Daily massage of lacrimal sac

• Warm Compresses

• Massage

• Referral to Optometry for Syringing of the nasolacrimal duct (for adults only)

Chloramphenicol for recurrent conjunctivitis in young children.

Systemic antibiotics for dacryocystitis, but requires relief of obstruction to prevent recurrence.

Referral to Secondary Care for Surgical intervention for epiphora secondary to lacrimal sac or nasolacrimal duct obstruction:

Referral to secondary care may be made for diagnostic purposes or tear duct syringing, however surgery is not routinely commissioned therefore prior approval must be obtained from the PCT’s Individual Funding Request Panel (NHS network connection required).

Refer to the IFR Panel for watery eyes surgery when, despite undergoing conservative management, the patient is experiencing a daily impact of significant watering of the eyes affecting visual function and / or interfering markedly with quality of life. The watering should occur both in outdoor and indoor settings.

Eyelid Ectropion

An ectropion is where the lower eyelid turns outwards away from the eye.

Part of the inner surface of the eyelid can be seen. Both eyes are usually affected.

Symptoms

• The inner lining of the eyelid that droops forward may become dry and sore.

• Watery eyes: the part of the eyelid next to the nose usually droops the most. This is next to the tear duct where tears normally drain into the nose. The drooping eyelid may prevent the tears from draining, and the eye may become constantly watery.

• Damaged Cornea: The eyes may not close properly therefore the cornea may be left unprotected. A corneal ulcer may develop.

Referral to Secondary Care

Surgery for eyelid ectropion is not routinely commissioned. Referral to the PCT’s Individual Funding Request Panel (NHS network connection required) may be made where patients are experiencing recurrent infection or inflammation.

Eyelid/Brow Ptosis (Droopy Eye) and Dermatochalasis (excess upper eyelid skin)

Surgery for eyelid ptosis or dermatochalasis, where the symptoms are purely cosmetic, will not be commissioned.

Referral to Secondary Care

Patients with objective demonstration of visual field restriction within 20 degrees of fixation on visual field testing, as measured by an optometrist, may be referred directly to Secondary Care.

In order to ensure effective implementation of the above guidance, GPs referring patients for surgery for eyelid ptosis or dermatochalasis should fill in the attached referral form  which should be forwarded directly to the patient’s chosen provider. Completing the form will provide a basis upon which to carry out clinical audits.

Directly referral to secondary care may also be made where a diagnostic ophthalmology opinion is required (e.g to exclude underlying causes such as thyroid related orbitiopathy, orbital tumours, iatrogenic horners syndrome, basal cell carcinoma and myasthenia gravis).

Eyelid Entropion

Entropion is a condition in which the eyelid margin turns in against the eyeball causing rubbing of the lashes and eyelid skin against the eye surface (the cornea). Involutional or senile entropion is one of the most common lower lid malpositions experienced by older people. A systematic review (Cochrane Database 2002) reported that, since no studies met the inclusion criteria, no results could be produced. The authors found that there was not enough evidence from trials either to compare surgical treatments or to assess adverse effects. The need for further RCT’s in the fields of entropion management was therefore highlighted. In the early stages entropion is asymptomatic, but eventually every movement of the eye or eyelid causes trauma to the corneal surface which may lead to infection and ulceration with visual impairment.

Symptoms:

• Irritation and pain on the front of the eye.

• Watery eyes

• Damaged Cornea: If left untreated, the cornea may become damaged and a corneal ulcer may develop.

Referral to Secondary Care

Referral should be made to secondary care when the condition is symptomatic and risks causes trauma to the cornea. While awaiting an operation a lubricating eye ointment may be prescribed to help protect the cornea.

In order to ensure effective implementation of the above guidance, GPs referring patients for eyelid entropion surgery should fill in the attached referral form  which should be forwarded to the relevant Acute Trust. Completing the form will provide a basis upon which to carry out clinical audits.

This guidance has been informed by:

Royal College of Opthalmologists Guidelines which are available at:
www.microphth.com/focus1/Management%20of%20Epiphora.htm

Interventional Procedure Guidance Number 113 (2005) re Endoscopic Dacryocystorhinostomy available at: www.nice.org.uk

Information for patients on the conditions described here is available at
www.patient.co.uk/showdoc/40024627 and www.nice.org.uk

Boboridis Kostas G, Bunce Catey (2002) Interventions for involutional lower lid entropion: A Systematic Review. Cochrane accessed via http://www.library.nhs.uk/EYES/ViewResource.aspx?resID=237571&tabID=289