Domain – Eye presentations (case)

Germain is a 29-year-old Aboriginal man who works for a local aged care provider as a driver. His employer has made this appointment as a matter of urgency, requesting an assessment of Germain’s vision, as he hit a bollard with the community bus this morning.

Germain has stated that he didn’t see the bollard, which was on the driver’s side of the car. The insurer has stipulated that he must have a satisfactory vision assessment before he can go back to driving for work. Germain is the only staff member with a commercial driver licence. He was diagnosed with type 2 diabetes and hypertension at the age of 22, and is currently prescribed metformin, irbesartan and atorvastatin. He is a patient of the practice, but this is the first time you have seen him.

Communication and consultation skills

What strategies could you use to establish a therapeutic relationship with an Aboriginal or Torres Strait Islander patient?

What strategies would you use to assess Germain’s health literacy and tailor your approach for him?

How would you communicate your decision if you decide that Germain is not fit to drive?

Establishing a Therapeutic Relationship

1. Cultural Competence:
   • Educate yourself about Aboriginal and Torres Strait Islander cultures, histories, and health beliefs.
   • Show respect for Germain’s cultural background, using appropriate language and terms.
2. Building Trust:
   • Introduce yourself and your role clearly.
   • Allow time for Germain to share his story without rushing.
   • Listen actively and empathetically, showing genuine interest in his well-being.
3. Community Engagement:
   • Involve Aboriginal health workers or liaison officers if available.
   • Recognize the importance of family and community, and consider involving them in the discussion if Germain is comfortable with that.
4. Non-Verbal Communication:
   • Be mindful of body language, maintaining an open and non-threatening posture.
   • Avoid direct eye contact if it seems to make Germain uncomfortable, as this can be perceived differently in various cultures.

Assessing Health Literacy and Tailoring Your Approach

1. Plain Language:
   • Use simple, non-medical language to explain health concepts and instructions.
   • Avoid jargon and complex terms that might be confusing.
2. Teach-Back Method:
   • After explaining a concept or instruction, ask Germain to repeat it in his own words to ensure understanding.
   • This helps identify areas that may need further clarification.
3. Visual Aids:
   • Use diagrams, pictures, or models to explain medical conditions and treatment plans.
   • Visual aids can be particularly helpful in conveying complex information.
4. Cultural Sensitivity:
   • Be aware of any cultural beliefs or practices that may influence Germain’s understanding of his health and treatment.
   • Tailor your explanations to be culturally appropriate and relevant.

Communicating Decision About Fitness to Drive

1. Clear Explanation:
   • Clearly explain the reasons for your decision, linking it to Germain’s safety and the safety of others.
   • Use empathetic language to show understanding of the impact this decision may have on him.
2. Supportive Resources:
   • Offer support and resources, such as referrals to specialists for further evaluation or treatment.
   • Provide information on other roles or tasks he could perform while addressing his vision issues.
3. Collaborative Approach:
   • Involve Germain in the decision-making process, discussing the options and implications together.
   • Ensure he understands the steps needed to regain his fitness to drive if possible.
4. Follow-Up:
   • Arrange follow-up appointments to reassess his condition and provide ongoing support.
   • Keep communication open and ensure Germain feels supported throughout the process.

How would your approach differ if there had not been an accident, but you noted that Germain had reduced vision at a general check-up?

?diabetic retinopathy

Clinical information gathering and interpretation

What information would you collect through history-taking and examination in this case?

1. Medical History:
   • Detailed history of diabetes management, including duration, glycemic control, and complications.
   • History of hypertension and its management.
   • Current medications (metformin, irbesartan, atorvastatin) and adherence to them.
   • Any history of eye problems or previous eye examinations.
2. Symptoms:
   • Onset, duration, and progression of vision changes.
   • Presence of any other symptoms such as eye pain, redness, discharge, floaters, or flashes of light.
   • Impact of vision changes on daily activities, including driving.
3. Lifestyle and Social History:
   • Diet, exercise habits, and smoking status.
   • Occupational details and any recent changes in job duties or work environment.
   • Family history of eye diseases or diabetes-related complications.
4. Cultural and Social Factors:
   • Understanding of health literacy, particularly regarding diabetes and vision health.
   • Any cultural beliefs or practices that might influence health care.

Examination

1. Visual Acuity:
   • Measure visual acuity using a Snellen chart or an alternative method if the patient is functionally illiterate (see below for details).
2. Ophthalmoscopy:
   • Perform a fundoscopic examination to check for diabetic retinopathy, hypertensive retinopathy, or other retinal changes.
3. External Eye Examination:
   • Inspect for signs of infection, inflammation, or other abnormalities in the eyelids, conjunctiva, cornea, and sclera.
4. Intraocular Pressure:
   • Measure intraocular pressure to rule out glaucoma.
5. Pupil Reactions:
   • Assess the pupillary light reflex and accommodation.
6. Visual Fields:
   • Conduct a visual field test to detect any peripheral vision loss.

What if Germain presented with eye pain or with a unilateral red eye or discharge from the eye?

1. History:
   • Onset and duration of eye pain, redness, or discharge.
   • Nature and severity of pain (sharp, dull, constant, intermittent).
   • Presence of other symptoms like photophobia, tearing, or blurred vision.
   • Recent trauma or contact lens use.
   • Any systemic symptoms like fever or headache.
2. Examination:
   • Inspect the eye for signs of conjunctivitis, keratitis, scleritis, or uveitis.
   • Assess for any foreign bodies or corneal abrasions.
   • Check for preauricular lymphadenopathy.
   • Fluorescein staining to identify corneal ulcers or abrasions.
   • Slit-lamp examination if available to assess anterior chamber for inflammation or hypopyon.

How would you assess visual acuity in a patient who is functionally illiterate?

1. E-Chart (Tumbling E Chart):
   • Use an E-chart where the patient indicates the direction of the “E” using their fingers or a pointer.
2. Picture Charts:
   • Use charts with pictures or symbols that the patient can recognize and describe.
3. Counting Fingers:
   • At various distances, ask the patient to count the number of fingers you are holding up.
4. Hand Movements and Light Perception:
   • Assess the ability to detect hand movements at various distances.
   • Check for light perception by shining a light into the patient’s eyes and asking if they can see it.

Making a diagnosis, decision making and reasoning

What is your differential diagnosis?

1. Diabetic Retinopathy: Given Germain’s history of type 2 diabetes, diabetic retinopathy is a significant possibility. It is a common complication of diabetes and can lead to vision problems if not managed properly.
2. Hypertensive Retinopathy: His history of hypertension could contribute to hypertensive retinopathy, which can cause changes in the retinal blood vessels and affect vision.
3. Refractive Errors: This includes myopia, hyperopia, astigmatism, or presbyopia, which could result in blurred vision.
4. Cataracts: Diabetes can increase the risk of cataract formation, which could impair his vision.
5. Glaucoma: This condition can be asymptomatic initially but can lead to progressive vision loss if not diagnosed and treated early.
6. Optic Neuritis: This could be related to diabetes or other inflammatory conditions, causing pain and vision changes.
7. Retinal Detachment: Although less common, it can cause sudden vision changes and requires urgent attention.

Germain says that he has pain in his right eye. How does this information change your differential diagnosis?

Additional Information: Right Eye Pain

With the addition of right eye pain, the differential diagnosis includes:

1. Acute Angle-Closure Glaucoma: This is a medical emergency characterized by sudden onset of eye pain, headache, blurred vision, and sometimes nausea and vomiting.
2. Optic Neuritis: As mentioned, inflammation of the optic nerve can cause eye pain, especially with movement, and vision loss.
3. Uveitis: Inflammation of the uvea can cause pain, redness, and blurred vision.
4. Corneal Abrasion or Ulcer: Trauma to the eye or infection can cause pain and vision changes.
5. Foreign Body: A foreign body in the eye can cause pain and affect vision.
6. Migraine: Ocular migraines can present with visual disturbances and pain.

Clinical management and therapeutic reasoning

What is your management plan for Germain?

Management Plan for Germain

1. Immediate Assessment:
   • Perform a thorough history and physical examination focusing on the vision problem and eye pain.
   • Measure visual acuity in both eyes.
   • Check intraocular pressure (IOP).
   • Conduct a slit-lamp examination.
   • Perform fundoscopy to evaluate the retina and optic nerve.
2. Referral to Ophthalmologist:
   • Refer to an ophthalmologist immediately if conditions like acute angle-closure glaucoma, retinal detachment, or optic neuritis are suspected.
   • Arrange for an urgent appointment if there are significant findings like severe vision loss, high IOP, or significant retinal changes.
3. Diabetes and Hypertension Management:
   • Review and optimize control of diabetes and hypertension, as these can contribute to eye problems.
   • Ensure Germain is adherent to his medications (metformin, irbesartan, and atorvastatin).
4. Pain Management:
   • Provide appropriate analgesics for eye pain if necessary and safe.

When would you refer him?

1. Factors Prompting Urgent Retrieval:
   • Sudden severe vision loss.
   • Acute angle-closure glaucoma symptoms (severe eye pain, nausea, vomiting, headache, vision loss).
   • Retinal detachment signs (flashes of light, floaters, shadow or curtain over vision).
   • Significant eye trauma or infection.
   • High IOP not responding to initial treatment.

How would you organise referral if you were in a rural or remote location? What factors or findings would prompt an urgent retrieval?

• Contact the nearest ophthalmologist or eye specialist service.
• Use telehealth services for initial consultation if available.

In addition to an ophthalmological history and examination, are there any screening activities that you would include in this consultation?

1. Comprehensive Ophthalmological History:
   • Duration and progression of vision changes.
   • Presence of eye pain, redness, discharge, or trauma.
   • Any history of previous eye problems or surgeries.
   • Family history of eye diseases.
   • Current medications and adherence.
2. Additional Screening:
   • Blood glucose levels and HbA1c to assess diabetes control.
   • Blood pressure measurement to evaluate hypertension control.
   • Lipid profile if not recently checked, considering atorvastatin therapy.

What aspects would you consider when assessing fitness to drive and fitness to work?

1. Fitness to Work:
   • Assess Germain’s ability to perform his job duties safely, particularly driving.
   • Consider the impact of his vision on other tasks he may perform.
   • Evaluate any other health conditions that may affect his work performance.
   • Collaborate with occupational health services if necessary for a comprehensive evaluation.

Follow-Up and Monitoring

• Schedule regular follow-ups to monitor his vision, especially given his diabetes and hypertension.
• Ensure continued coordination with his primary care provider for ongoing management of his chronic conditions.
• Educate Germain about the importance of routine eye examinations and adhering to treatment plans for diabetes and hypertension to prevent future complications.

Fitness to drive

Visual Fields Summary

• Definition and Norms:
  • Visual fields measure peripheral (side) vision.
  • Normal visual field: 60° nasally, 100° temporally, 75° inferiorly, 60° superiorly.
  • Binocular field: 160-200° horizontally, 120° central overlap for stereopsis.
• Causes of Reduced Visual Fields:
  • Neurological conditions (e.g., stroke, multiple sclerosis).
  • Ocular diseases (e.g., glaucoma).
  • Injuries, leading to hemianopia, quadrantanopia, or monocularity.
• Driving Implications:
  • Peripheral vision is crucial for environmental awareness while driving.
  • Central fovea moves to identify important information alerted by peripheral vision.
  • Incomplete peripheral vision loss allows some awareness; adaptation possible by scanning.
  • Intellectual/cognitive capacity impacts the ability to adapt to visual defects.
  • Longstanding field defects may lead to visual adaptation; assessed for conditional license.
• Horizontal Visual Field Extent:
  • Private vehicle drivers: 90-110° horizontal field may grant conditional license.
  • Commercial vehicle drivers: No flexibility below 110°.
  • Single clusters of up to three missed points or single vertical defects may be disregarded if unattached.
• Central Field Loss:
  • Acceptable: Scattered single points or a cluster of up to three points.
  • Unacceptable: Clusters of four or more points within central 20°, or extensions of hemianopia/quadrantanopia greater than three points.
  • Changes as of 2022: New criterion: significant field loss (scotoma) with more than four contiguous spots within 20° radius from fixation disqualifies for unconditional license.
• Measuring Visual Fields:
  • Consider real-world demands: kinetic fields, binocular Esterman, contrast sensitivity, glare susceptibility, medical history, driving record, driving task nature.
  • Monocular vision: Conditional license if 110° horizontal field and satisfactory acuity in the better eye.
  • Monocular commercial drivers: 140° horizontal field, satisfactory acuity, regular reviews.
  • Changes as of 2022: New criterion: significant field loss (scotoma) with more than four contiguous spots within 20° radius from fixation disqualifies for unconditional license.
• Monocular Vision (One-Eyed Driver) Summary
  • Visual Field Reduction:
    • Reduction due to nose obstructing the medial visual field.
    • Lack of stereoscopic vision and other potential visual deficits.
  • Private Vehicle Drivers:
    • Conditional license considered if horizontal visual field is 110°.
    • Visual acuity must be satisfactory in the better eye.
  • Commercial Vehicle Drivers:
    • Generally not fit to drive.
    • Conditional license considered if:
      • Horizontal visual field is 140°.
      • Visual acuity in the better eye is satisfactory.
      • No other visual field loss likely to impede driving.
      • Assessment by an ophthalmologist/optometrist deems the person safe to drive.
    • The better eye must be reviewed at least every two years.
• Sudden Loss of Unilateral Vision:
  • Adaptation period advised (usually three months).
  • Notify licensing authority and reassess based on visual field standard.
• Diplopia:
  • Generally unfit to drive except minor forms.
  • Non-driving period for occluder management (three months).
  • Changes as of 2022:
    • Commercial license disqualification if double vision within 20° from fixation.
    • Conditional license possible for double vision beyond 20°.
    • Clarified definition of diplopia within central 20°.

Professionalism

In this context, to whom do you owe duty of care? Does this change if you find that Germain is not fit to drive?

Duty of Care

1. To Germain:
   • As Germain’s physician, your primary duty of care is to him. This includes providing an accurate diagnosis, appropriate treatment, and honest advice regarding his health and ability to perform his job safely.
   • Ensuring Germain understands his health conditions, the potential risks associated with his vision impairment, and the necessary steps to manage his conditions effectively.
2. To the Employer:
   • You have a responsibility to provide an accurate assessment of Germain’s fitness to drive, as requested by his employer. This includes completing any necessary forms or reports accurately and honestly.
   • Ensure confidentiality of Germain’s medical information while providing the employer with the relevant information regarding his ability to safely perform his job duties.
3. To the Public:
   • There is a broader duty of care to the public, particularly when it involves public safety issues such as the fitness of a commercial driver. This includes ensuring that only individuals who meet the necessary health and vision standards are allowed to drive, thereby reducing the risk of accidents and injuries.

If Germain is Not Fit to Drive

If you determine that Germain is not fit to drive, your duty of care involves:

1. Communication with Germain:
   • Clearly explaining the reasons why he is not fit to drive, the potential risks involved, and the steps he needs to take to improve his health or manage his conditions.
   • Discussing alternative arrangements or modifications to his job duties that could accommodate his health condition.
2. Communication with the Employer:
   • Informing the employer of Germain’s unfitness to drive in a way that respects patient confidentiality while fulfilling your professional responsibility. Provide only the necessary information related to his fitness for duty.
   • Collaborating with occupational health services, if available, to help the employer understand Germain’s limitations and explore possible accommodations or alternative roles.
3. Reporting Obligations:
   • Depending on local laws and regulations, you may have a legal obligation to report Germain’s unfitness to drive to the appropriate licensing authority to ensure public safety.
   • Ensuring Germain is aware of this reporting obligation and the potential consequences.
4. Follow-Up and Support:
   • Providing ongoing support and monitoring to Germain to manage his health conditions and reassess his fitness to drive in the future.
   • Offering referrals to other healthcare professionals or support services as needed to address his health needs and any implications for his employment.

Legal and Ethical Considerations

• Confidentiality: Maintain Germain’s confidentiality while balancing the need to communicate necessary information to the employer and possibly to regulatory authorities.
• Informed Consent: Ensure Germain is fully informed about his health status, the reasons for your assessment, and the implications for his job and driving license.
• Professional Guidelines: Follow relevant professional and legal guidelines regarding fitness to drive assessments and reporting obligations.

Your duty of care remains primarily with Germain, ensuring his health and safety, while also considering the safety of the public and the requirements of his employer.

General practice systems and regulatory requirement

You refer Germain to the local optometrist for assessment. How would you use your practice software to ensure follow-up occurs?

How would you explain the confidentiality issues for this consultation?

Procedural skills

What are your obligations if you find Germain’s vision does not meet the standard of being fit to drive? What are your obligations with respect to his employment?

How would you assess intraocular pressure?

Managing uncertainty

You find that Germain has a corneal foreign body. How would you remove this?

• General Removal:
  • Most corneal FBs can be removed at the slit lamp.
  • Prompt removal minimizes risk of infection, inflammation, scarring, and vision loss.
  • Delay in removal can lead to deeper embedding and possible corneal perforation.
  • Glass and fiberglass FBs may be monitored if removal risks more damage.
  • Deeply embedded FBs or those risking perforation should be removed in the operating room.
• Anesthesia and Procedure:
  • Use topical anesthetics (proparacaine hydrochloride 0.5% or tetracaine hydrochloride 0.5%) for patient comfort.
  • Hold eyelids open gently; patient fixates on a target.
  • Use a 25- or 27-gauge needle at an oblique or tangential angle to lift the FB.
  • Jeweler’s forceps for plant/vegetable matter, embedded FBs, or adherent superficial FBs.
  • Magnetic spud for metallic FBs; moist cotton-tipped applicator for superficial, loosely adherent FBs.
  • Irrigation for multiple small particles.
• Post-Removal Care:
  • After metallic FB removal, address any rust ring using a needle, jeweler’s forceps, or an Alger brush.
  • Aim to remove rust without causing excessive tissue disruption or perforation.
• Final Assessment:
  • Reevaluate cornea for residual particles.
  • Assess depth of excavation and epithelial defect extent.
  • Conduct Seidel testing for deep residual defects.

Identifying and managing the significantly ill patient

How would you manage this situation if you found no red flags?

Management Plan if No Red Flags

1. Comprehensive Eye Examination:
   • Assess visual acuity.
   • Check intraocular pressure.
   • Conduct slit-lamp examination.
   • Perform fundoscopy.
2. Pain Management:
   • Provide topical anesthetic drops for immediate relief.
   • Prescribe antibiotic eye drops if there’s a risk of infection.
3. Reassurance and Monitoring:
   • Educate Germain about his condition and reassure him.
   • Schedule a follow-up appointment to reassess his vision and eye health.
4. Referral to Optometrist/Ophthalmologist:
   • Arrange a non-urgent referral if no immediate threats are found, for a detailed assessment and to ensure fitness to drive.

What are the red flags/clinical findings that would prompt urgent referral? Which eye emergencies could present in this manner?

Eye Emergencies that Could Present in This Manner

1. Acute Angle-Closure Glaucoma: Characterized by sudden pain, vision loss, headache, and nausea.
2. Retinal Detachment: Presents with floaters, flashes of light, and a shadow or curtain over vision.
3. Optic Neuritis: Inflammation of the optic nerve causing pain and vision changes.
4. Corneal Ulcer or Severe Abrasion: Infection or trauma to the cornea causing significant pain and vision impairment.
5. Uveitis: Inflammation of the uvea presenting with pain, redness, and vision changes.
6. Endophthalmitis: Severe infection within the eye, often post-surgical or post-trauma.