Abstract
Background: Acute anterior uveitis (AAU) is a potentially serious ocular condition, which frequently presents to the General Practitioner (GP). In some cases, it can be misdiagnosed with consequent delay in the initiation of appropriate treatment.
Objectives: To analyse the diagnostic features of AAU presenting to the emergency service at Manchester Royal Eye Hospital; to investigate the prior management of AAU in the community and identify management problems amenable to constructive feedback. Methods: A list of reasonable standards expected from primary carers was compiled and information collected prospectively by nurse practitioners over two months using a specifically designed pro-forma. Data was analysed against these standards and compared to the relevant literature.
Results: Of the AAU patients 18/69 had previously seen the GP. 14 had first episodes, 4 were recurrent. Mean interval between symptom onset and eye emergency attendance was 9.2 days compared to 4.3 days for those not seen by GP. Symptoms elicited, in those previously seen by a GP, were: ocular pain (18/18); photophobia (17/18); unilateral red eye (17/18); and blurred vision (15/18). GP performed ocular examination in 12 patients. Seven patients were not treated by GP but referred on the same day. The other 11 patients were prescribed topical antibiotics by GP and 2/11 also received topical steroid. 9 of these 11 patients eventually self-checked into eye emergency, whereas two were subsequently referred after re-visiting the GP.
Conclusion: A significant number of AAU patients present to the GP and may be misdiagnosed with an alternative condition such as conjunctivitis. Awareness of AAU presentation and the need for prompt referral, to avoid potential visual loss, needs to be improved by providing feedback to GPs following patient attendance to eye emergency services.
KEY MESSAGE(S):
Timely diagnosis is essential for referral for treatment of acute anterior uveitis
In patients presenting with a ‘red eye’, key symptoms that should raise suspicion of acute anterior uveitis are unilaterality, pain, photophobia, and blurred vision
Pen-torch examination and visual acuity testing provide essential information for referral
Introduction
Uveitis has an annual incidence of 15–20/100 000 per annum and unilateral AAU is by far the most common form of uveitis (Citation1). A general ophthalmologist in the UK would expect to see a new patient once every three weeks; in secondary care it is a common disease. However, in primary care it is relatively infrequent in comparison with conjunctivitis, the commonest cause of a red eye. Nevertheless, unilateral AAU presents with recognizable and distinct symptoms and signs. Correct initial management speeds recovery, reduces pain and minimizes the cumulative risk of complications with each attack; these risks can be substantial and uveitis can be a blinding disease.
Acute uveitis is characteristically moderately painful with intense photophobia and visual blur. It usually causes conjunctival redness particularly around the cornea (ciliary injection). In contrast, conjunctivitis is usually bilateral, mildly uncomfortable with no evidence of photophobia or significant blur. Redness is greatest in the peripheral conjunctiva. Some atypical forms of conjunctivitis (characteristically more severe) begin unilaterally, as do acute corneal abnormalities. All such patients benefit from prompt referral to an ophthalmologist.
Management of AAU includes the urgent instillation of mydriatic and cycloplegic agents to break iris adhesions and to provide analgesia; the administration of intensive topical and/or sub-conjunctival steroid to reduce inflammation; and expert slit-lamp supervision to exclude posterior uveitis, to supervise recovery and to manage complications including acute secondary glaucoma. If treated inadequately, uveitis leads to permanent iris-lens and iris-cornea adhesions and when recurrent, to glaucoma or phthisis and permanent visual loss.
AAU may present to the General Practitioner (GP) in the community, especially during the first episode. GPs are not expected to manage uveitis and should not prescribe topical steroid for an undiagnosed red eye mainly because of the danger of exacerbating a missed herpetic corneal ulcer (Citation2). However, generating a suspicion of uveitis based upon elicited symptoms and naked-eye examination is expected, with consequent prompt onward referral. It has been our experience that patients presenting to our hospital emergency service with unilateral AAU had sometimes been initially managed as presumed conjunctivitis in the community. This may delay initiation of appropriate treatment for an often painful and potentially vision-threatening condition. This study aimed to investigate this potential problem and to identify means of improving the diagnosis and management of AAU in the community.
Methods
Design
The study design consisted of a cross-sectional community survey of patients diagnosed with AAU after attending the Emergency Eye Centre (EEC) at Manchester Royal Eye Hospital, a unit, which serves a population of over one million and reviews around 25 000 acute ophthalmic patients per year.
A set of core diagnostic and management skills expected from a GP was developed by the authors’ consensus for subsequent use as standards for data comparison (). An anonymous paper-based pro-forma was specifically designed for data collection and a standardized set of direct patient questions used to detail the prior management of each patient in the context of these diagnostic features.
Table I. A standard for data comparison.
Patient selection
Data was collected retrospectively by ophthalmic nurse practitioners in EEC from all patients attending with AAU over a continuous two-month period (May to June 2009). Patients were identified by triage nurses in EEC and recruited into the study following confirmation of the diagnosis of AAU by the examining Ophthalmologist. Patients presenting with any of the symptoms described below but not diagnosed with AAU were excluded from the study.
Data collection (patient interviews)
A list of specific presenting symptoms was asked and recorded for each patient: unilateral red eye; bilateral red eye; photophobia; discharge/watering; ache/pain; blurred vision. The patient was then asked whether the episode was a first or recurrent. Date of symptom onset was also noted to establish a timeline of diagnosis, referral and treatment. Each patient was then asked whether they had consulted a GP before attending the Eye Centre. Those with affirmative responses were further asked about date seen by GP, date and time frame of referral (if any), type of treatment initiated (if any) and whether a visual acuity check and ocular examination had been performed.
Analysis
The data collected was entered into a Microsoft Excel® 2007 spreadsheet and a descriptive analysis of our findings was performed with results being compared to the core diagnostic and management skills referred to earlier ().
Results
69 patients with AAU attended over two months. 61 cases were unilateral. 28 patients were suffering their first episode, 41 were recurrences. The mean patient age was 46 years (range: 15–73).
46 patients were self-referrals. 18 patients had been previously reviewed by their GP. Two others had seen an optician and one each were initially assessed by an Accident & Emergency doctor, a private refractive clinic and a pharmacist. The mean interval between onset of symptoms and EEC attendance after the first GP consultation was 9.2 days (range@ 2–30 days) compared to 4.3 days (range: 1–28 days) for those patients not seeing their GP.
Of the 18 patients initially presenting to their GP, 17 had unilateral disease. 14 had first episodes of AAU, 4 were recurrent. The symptoms presenting to the GP by these 18 patients are described and quantified in and compared to the self-referred patients.
Table II. Symptoms presented by patients with AAU.
An eye examination had been undertaken by the GP in 12/18 patients, 9 with pen torch or ophthalmoscope (including 4 who had vision tested). 7 patients were not treated by the GP and referred to EEC on the same day. All of these 7 patients had been examined with a light source. The remaining 11 were initially treated by their GP without referral; 9 were prescribed topical antibiotic alone (7 chloramphenicol, 2 fusidic acid) and 2 were treated with topical antibiotic plus topical steroid (prednisolone 0.1% with chloramphenicol and dexamethsone 0.1% with neomycin). 2 of these returned to their GP after three and five days of treatment and were then referred to EEC. 9 eventually self-presented to EEC without consulting their GP again.
Discussion
Main results
This study indicates that most patients with AAU self-refer to ophthalmic emergency services. However, a significant number present to primary care, giving GPs a crucial role in the early diagnosis and appropriate management of the condition. The increased mean interval between symptom onset and eye casualty evaluation also reveals how timely assessment and referral is important.
Those diagnosed with AAU in secondary care are informed of the recurrent nature of the condition and advised to seek early ophthalmic review should they have a future episode. These patients are, therefore, less likely to present to their GP. Most patients presenting to the GP in this study were first episodes of AAU, making the diagnosis more challenging.
The study points out that a basic eye examination is crucial to the correct diagnosis and prompt management of AAU. All 7 patients referred immediately to EEC had been examined with a light source by the GP. Light source examination and visual acuity testing provide simple but essential information that must be included in the referral of patients to an ophthalmology service. Unfortunately, only 50% of patients actually in our study had a pen torch or ophthalmoscopy examination and less than 25% had their visual acuity documented.
The overall results show that there is wide variation in the diagnosis and management of anterior uveitis by GPs with more than half of the patients assessed being prescribed topical antibiotics in the first instance. This reflects the diagnostic difficulties when dealing with a ‘red eye’ in general practice and show potential pitfalls when dealing with such cases.
Study limitations
The aim of the study was to take an overall snapshot of the presentation and initial management of AAU within a large patient population. 69 cases collected over a two-month period seems to adequately depict the general incidence of AAU but there was no way of determining how many additional cases did not present to EEC due to successful treatment by GPs, management by private care providers, spontaneous resolution or self-management with topical steroid.
Data collection was also limited by the retrospective study design. This did not allow verification of details of the ophthalmic examination performed prior to referral nor the eventual complications, such as chronic synechiae or secondary glaucoma, related to delayed or incorrect management.
Implications for practice
The management of red eye in primary care has been a frequent topic for discussion. Several publications have tried to tackle the topic and useful clinical guidelines or algorithms are available to increase awareness and provide reference to general practitioners and physicians (Citation3–6). To the best of our knowledge, there are no studies in the literature looking specifically at the management of AAU in the community and its referral to ophthalmic services.
Some patients in our study could have been more effectively managed in the community. This might reflect a lack of confidence in dealing with ophthalmic problems (as evidenced by the low number of GPs performing an eye examination), a lack of understanding of the clinical signs and symptoms of AAU (as evidenced by the initiation of treatment for conjunctivitis) or simply a diagnostic challenge when dealing with the early onset of a first episode of anterior uveitis. The speed of referral in uveitic patients can be crucial in avoiding sight-threatening complications and the increased mean treatment delay in patients presenting to general practice highlights the need for better diagnostic and referral protocols, potentially aided by improved communication and education between the GP and the ophthalmologist. The importance of feedback is also an important take home message from these results. In our case, the anonymity of the survey meant that specific individuals or practices potentially amenable to constructive feedback could not be identified.
Implications for research
An ideal situation would be to set up a local or multicentre study between GPs and Ophthalmologists to investigate and inform this situation better. In the meantime, the authors hope that this publication helps disseminate the message for increased awareness of the potentially blinding condition of anterior uveitis and the importance of good communication and constructive feedback between the various health care professionals involved in dealing with patients presenting with AAU.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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