Quiz 1

68 year old man presents with sudden

painless loss of vision right eye
Whit next?

quiz 1 pic of the fundus

Quiz 2
78 year old woman presents with painful
inflamed right eye
Whit next?

Pic of the affected eye

Quiz 3
28 year old man presents with acute onset
diplopia
Whit next?

Pic of the patient

Quiz 4
78 year old woman presents with a watery
right eye
Whit next?

Pic of the patient

Quiz 1 & algorithm

68 year old man presents with sudden
painless loss of vision right eye
Whit next?

Visual Loss Algorithm

Quiz 1
pupil reactions

Pic of the fundus

Quiz 2 & algorithm

78 year old woman presents with painful
inflamed right eye
Whit next?

Red Eye Algorithm

Pic of the affected eye

Quiz 3 & algorithm

28 year old man presents with acute onset
diplopia
Whit next?

Diplopia Algorithm

Pic of the patient

Quiz 4 & algorithm

78 year old woman presents with a watery
right eye
Whit next?

Pic of the patient

Mark Wright Consultant

Ophthalmologist Lothian Health
and Edinburgh University
Algorithm based clinical teaching
does it work?
elos/nes 2.2.16

Role & training of optometrists

Optometrists are extending their role both diagnostically
and therapeutically & slowly taking over the role of GPs
in managing primary care ophthalmology
Greater clinical expertise required by the 2006 GOS
contract however HES reluctant to devote time to
optometry/orthoptic teaching because of service
pressures
Could algorithm based clinical teaching help?

Is there a place for diagnostic

algorithms in ophthalmology?
A partial solution to the ever increasing pressure on
hospital eye services (HES) is to improve the partnership
between community optometrists and HES
The following slides illustrate the results of three
prospective clinical trials which document the accuracy of
the Edinburgh Eye Algorithms (5) when used by
inexperienced clinicians in the three most commonly
encountered clinical scenarios; red eye (s), visual loss
and diplopia
They highlight the existing diagnostic deficiencies within
our referral groups and demonstrate the significant
improvement in these deficiencies when our simple
diagnostic algorithms are applied to patients presenting
with red eye (s), visual loss and diplopia

Edinburgh Red Eye Algorithm

Baseline diagnostic accuracy for non ophthalmologists
for patients presenting with AACG was 21% (GPs) 64%
(A&E)1 and for iritis (GPs) 44%2
When equally inexperienced observers (GP 35%, A&E
nurse practitioners 23%, opticians 18% etc) assessed
patients presenting with red eye (s) using the Edinburgh
Red Eye Diagnostic Algorithm the diagnostic accuracy for
AACG rose to 100% (4/4 cases) and for iritis rose to 82%
(9/11 cases)
For all causes of red eye (s) the overall diagnostic
accuracy was 72% (28/39)3
1 Siriwardena D, Arora AK, Fraser SG, McClelland HK, Claoue C. Misdiagnosis of acute angle closure glaucoma. Age
Ageing. 1996;25(6):421-3.
2 Sheldrick JH, Vernon SA, Wilson A. Study of diagnostic accord between general practitioners and an ophthalmologist.
BMJ.1992; 304:1096-1098.
3 Accuracy of the Edinburgh Red Eye Algorithm. Eye 2015; 29: 619-624.

Edinburgh Visual Loss Diagnostic Algorithm

The overall pre-algorithm diagnostic accuracy of referrers assessing

patients presenting with visual loss was 51% (30/59). Individual accuracy
was; optoms 67%, A&E doctors 33%, GPs 13%, other hospital specialties
0%

The diagnostic accuracy improved to 84% (57/68) when inexperienced

observers (4th year medical student 45% [31/68], junior ophthalmology
trainee 37% opticians 18%) assessed the same cohort of patients using the
Edinburgh Visual Loss Diagnostic Algorithm4

The algorithm correctly diagnosed: retina in 71% of cases (5/7), macula in

86% (25/29), peripheral retina in 100% (2/2), optic nerve in 71% (5/7),
media opacity in 89% (16/18), post chiasmal in 100% (4/4) and refractive
error in 0% (0/1)

Accuracy of diagnosis was similar for each algorithm user; medical student
81%, inexperienced ophthalmology trainee 84% and optometrist 92%.

The Accuracy of the Edinburgh Visual Loss Diagnostic Algorithm. Accepted for publication in Eye
July 2015

Edinburgh Diplopia Diagnostic Algorithm

The overall pre-algorithm diagnostic accuracy of referrers assessing
patients presenting with diplopia was 24% (10/41). Individual
accuracy was; A&E & other hospital doctors 20%, GPs 44%, optoms
36%. In 54% of the cases (22/41) the referrer did not make an
attempt to diagnose the cause of the diplopia.
The diagnostic accuracy improved to 82% (37/45) When
inexperienced observers (FY2 & 5th year medical student) assessed
the same cohort of patients using the Edinburgh Diplopia Diagnostic
Algorithm5

The algorithm correctly diagnosed: CN III palsy in 6/6, CN IV palsy

in 7/8, cranial nerve (CN) VI palsy in 12/12, internuclear
ophthalmoplegia in 2/2, restrictive myopathy in 4/4, media opacity in
1/1 and blurred vision in 3/3. The 7 incorrect diagnoses included;
myasthenia gravis, Miller Fisher Syndrome,post head injury
diplopia and two cases of dual CN (CN 111 & IV and 111 & VI)
palsies.

5 The Accuracy of the Edinburgh Diplopia Diagnostic Algorithm; accepted eye January 2016

Edinburgh Eye Algorithms

These are the first diagnostic eye algorithms to be
subjected to scientific analysis and lead to significant
improvements in the diagnostic accuracy of
inexperienced clinicians in the three most commonly
encountered ophthalmic scenarios
We have offered these algorithms to all interested
parties; RCOph, College of Optometrists, RCEMedicine,
RCGP etc. with an app under development
A number of open access learning tools including
downloadable copies of the 5 diagnostic algorithms and
narrated lectures accompanying the algorithms are
available at
https://www.eemec.med.ed.ac.uk/pages/resources/mwophthalmology-page

Approach to patients presenting

with red eye(s)
KEY POINTS IN THE OCULAR EXAMINATION AND
DECISION MAKING POINTS IN THE RED EYE ALGORITHM

Unilateral vs bilateral redness

Always look at the lids before the eye(s)!
Presence of fluorescein staining esp. if the cornea is
clear
Corneal appearance; clear or hazy; focally or
diffusely hazy
Difference in the pupil size (anisocoria)
Presence of photophobia
(Pattern of redness; diffuse or sectorial)
Direct ophthalmoscope gives an illuminated
magnified view

Red Eye Algorithm

2 practical skills
Careful observation!

Use of fluorescein dye

Red Eye Algorithm

redness unilateral or bilateral?

Redness unilateral or bilateral?

bilateral red eyes

predominant ocular symptom?

predominant symptom itch

allergic conjunctivitis which is;
often associated with atopy; asthma,
eczema and hay fever
can be associated with a stringy more than
a purulent discharge
treatment is allergen avoidance if possible
and optanolol drops if not

predominant ocular symptom?

predominant symptom gritty

and burning with discharge
present
infectious conjunctivitis
the discharge is usually purulent
very difficult to distinguish bacterial from viral on
clinical grounds
Most will settle with no treatment, if it fails to
improve topical chloromycetin drops during the
day and ointment at night
Swab for chlamydia if symptoms persist

discharge present?

predominant ocular symptom

gritty and burning with no discharge
dry eyes
eyes are minimally red
almost always in older patients
Unilateral only in the presence of incomplete
closure i.e. facial nerve palsy
Treatment is long term ocular lubricants;
viscotears during the day and lacrilube at night

redness unilateral or bilateral?

Redness unilateral or bilateral?

unilateral red eye

Red eye; signs

The second thing to
check in a patient with
a red eye(s) is.

Red eye; signs-look at the

lids!

Lid margin lesions

Entropion/trichiasis
Lagophthalmos

lashes touching the eye?

lashes touching the eye

entropion or trichiasis

normal eyelid closure?

incomplete eyelid closure

facial nerve palsy

Red eye(s); the most important

single thing to do to a red eye(s)
is
1. Check the vision
2. Digitally estimate the intraocular
pressure
3. Instil fluorescein dye
4. Evert the lid looking for a sub tarsal F.B.
5. Check the pupil reactions

Red eye; signs- instil

fluorescein dye
Always instil
fluorescein dye into a
red or sore eye to
confirm/exclude an
epithelial keratitis
A clear cornea does
not equate to the
absence of an
epithelial keratitis

cornea stains with fluorescein

cornea stains but is clear

epithelial keratitis; infectious
(h.s.v.), trauma, chemical etc

cornea stains and is hazy

stromal keratitis; abscess

no corneal staining with fluorescein

Pupil larger on the red eye side

acute angle closure glaucoma

pupil same size or slightly smaller on the red eye side

photophobia present
iritis

photophobia absent

eye pain present

scleritis often associated with
ocular tenderness

eye pain absent

episcleritis not usually associated
with ocular tenderness

Approach to patients
presenting with visual loss
Key step is to map out the patients visual field defect
using confrontational visual fields which will allow you to
locate which part of the visual pathways are affected
Measure the visual acuity and if reduced again with the
pinhole
The only specialised test required is the swinging
flashlight test to determine whether an RAPD is present
Lastly, use the history and PMH/age etc to best guess
the likely cause and then confirm using the
ophthalmoscope

Visual Loss Algorithm

4 practical skills
Confrontational visual field
Visual acuity
Pupil reactions (rapd)

Fundoscopy

Visual loss
algorithm

Visual loss-confrontational V.F.

testing

Visual loss-swinging flashlight

test (RAPD)
Run the video clip of the RAPD

Visual loss
algorithm

Approach to patients presenting with

diplopia; clarify the history

Clarify the patient means they see two separate

images i.e. true diplopia and not one blurred image
Secondly ask if when the patient covers each eye
separately the double image goes i.e is the diplopia
monocular or truly binocular

Diplopia Algorithm
1 practical skill
Careful observation

Double vision
(diplopia)

Double vision
(diplopia)

Any Questions?
If time, quiz time!
MW is your patient!
A number of open access learning tools
including downloadable copies of the 5
diagnostic algorithms and narrated lectures
accompanying the algorithms are available
at
https://www.eemec.med.ed.ac.uk/pages/re
sources/mw-ophthalmology-page

Quiz 1
28 year old man presents with acute onset
diplopia
What next?

Diplopia Algorithm

Pic of the patient

Quiz 2
68 year old man presents with sudden
painless loss of vision right eye
What next?

Visual Loss Algorithm

Quiz 2
Show pupil reactions (RAPD video)

Pic of the fundus

Quiz 3
78 year old woman presents with painful
inflamed right eye
What next?

Pic of the affected eye

Quiz 4
8 year old boy presents with a difference
noted in his pupil sizes
What next?

Anisocoria Algorithm

Pic of the patient

Quiz 5
78 year old woman presents with a watery
right eye
What next?

Epiphora Algorithm

Pic of the patient