1. Do not trust anyone else’s history or exam.
ER docs and physician assistants are not trained in ophthalmology. Be appreciative, but perform a complete history and exam yourself.

2. The Will’s Eye Manual is your new best friend.
Especially early on, it may be worthwhile to read this manual before seeing the patient, as it will help direct the exam. It is an excellent resource before involving a senior resident and, especially, an attending. Thoroughly explore it before climbing the chain. You should also download the EHB Eye Handbook app for your smartphone You’ll have diagnostic pictures, treatment plans and tools, including a vision card and color plates, in the palm of your hand.

3. Buy reading glasses.
Go to the local dollar or drug store and pick up a pair of +3.00 glasses and even +1.50. This will make life easier when checking vision, especially in trauma patients requiring simultaneous lid retraction while holding the near card.

4. Bag it.
Prepare everything in a call bag: vision card, fluorescein strips, eye patches, suture for lid lacs, Desmarres retractors ($20 on eBay for four), drops, etc. Be minimally reliant on the ER staff.

5. Identify the tools available.
Every program and hospital has different instruments available. Know the most efficient ways to access the indirect, portable slit lamp and other critical instruments. Also, know where to find an ultrasound with an appropriate probe for B scans in the middle of the night.

6. Develop a routine.
Vision, pressure, pupils, drops! Developing an efficient exam will save tons of time in the middle of the night. Be aware that dilating is not an option in every circumstance. In addition, streamline the process for preparing ruptured globes for the OR. Include a to-do list in your call bag (e.g., make patient NPO, update tetanus, place shield, etc).

7. Know the coverage.
This may seem simple, but no one wants to waste time at night determining backup, especially if different attendings cover different hospitals. Have the schedule saved and easily accessible.

8. Get their digits.
Make sure to have a way to follow up with the patient. Certain diagnoses require close observation, e.g., preseptal cellulitis. Be able to contact the patient.

9. Give clear instructions.
This is very important when meeting people in distress at odd hours of the night. Make sure to write down all the pertinent instructions and contact information so the patient can follow them and follow up accordingly. In addition, write the assessment and plan in plain English for the ER physician to understand.

10. Copy the note.
Make a copy of the note for dictation and recording procedures as necessary.

Bonus.
Get some sleep! It may be a long night!

Issue Index

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About the author: James G. Chelnis, MD, is a resident at the University at Buffalo.