to see the doctor right away — and I don't have an appointment.” Staff is often on the receiving end of this request, either by phone or in person, and they need to decide quickly which patients should see a physician and when. These are vitally important decisions in your practice, and an error in staff judgment may cause needless patient discomfort, potential vision loss or a possible malpractice suit.
Anyone who has worked in an ophthalmologic practice very long understands why Friday afternoons and Monday mornings have the greatest number of frantic calls from patients. Friday afternoons are marked by calls from individuals who have waited all week for their problem to subside, but now it’s Friday and they don’t want to go to the ER over the weekend.
Monday-morning calls are from individuals who held out over the weekend, also not wanting to visit the ER. Given that there are only so many same-day, add-on patient appointment slots, it is important to be particularly diligent in triaging on these days to avoid an overwhelming patient load.
Front-desk staff may not be trained for this sort of evaluation, but physicians should be able to help triage ocular emergencies and schedule patients accordingly. Your practice can simplify the choices by dividing clinical presentation into four tiers:
- Emergent: See immediately
- Urgent: See today
- Priority: See this week
- Routine: Make an appointment
This article addresses conditions needing “emergent” care. By definition, an ophthalmic emergency requires immediate medical attention to avert permanent visual impairment. Left untreated, ophthalmic emergencies can lead to permanent loss of visual function.
Conditions that require an emergent workup include:
- Acute vision changes
- Penetrating and non-penetrating traumatic injuries
- Chemical injuries
- Acute angle-closure glaucoma
- Foreign body sensation with inability to open the eye
- Orbital cellulitis
- Retinal detachment
A detailed or comprehensive history is warranted to identify emergent situations. An ophthalmologist should be summoned immediately when the patient has obvious eye trauma; the history and exam can be completed in the meantime. In a chemical exposure trauma, however, immediate eye irrigation is mandatory.
Initial questioning should focus on determining whether the problem is traumatic, inflammatory or neurovascular. The technician should ask about prior surgeries or contact lens use, which may be helpful in determining infectious causes. The medical, family and social histories can suggest risk factors for inflammatory or neurovascular etiologies. Query current and recent medications to determine if antibiotics or topical steroids suggest an infectious etiology.
Although it may be difficult to determine which symptoms threaten vision and require emergent care, a careful patient history may uncover several important symptoms. These include reduced visual acuity; visual field changes; floaters; photopsia; head, orbital or ocular pain; changed appearance of the ocular adnexa; ptosis; diplopia and alterations in pupil size. If the symptoms are severe or rapidly progressive, urgent referral to an ophthalmologist is appropriate.
Past ophthalmic and general medical history provide background for the current symptoms. It is important to determine whether the current condition could be a recurrence or a complication of a previous ophthalmic condition. Always ask about any recent ophthalmic or orbital surgery.
Patient history provides important clues to the diagnosis. The onset and duration of symptoms, current ocular conditions and immediate ocular history can often help differentiate particular diagnoses and lead to appropriate treatment.
- In cases of trauma, particular importance must be given to the environment preceding the injury. Small, sharp, high-velocity objects, for example, resulting from hammering metal on metal or using a grinder, often produce penetrating injuries.
- An accident or a fall may cause blunt trauma and presents different issues. Particular care should be given to noticing the presence of foreign bodies, chemosis, corneal haze and blood or pus in the anterior chamber of the eye.
- If a full-thickness corneal injury is present, aqueous humor may be seen. This requires emergency attention.
- The presence of a pupillary defect is an important diagnostic sign. Pupil examination must be completed before any dilating agents are used.
Visual acuity is often the most important marker of an emergency condition and provides a useful guide to the current condition and its long-term potential. Accurate assessment of visual acuity can be challenging at times due to the patient's general condition and ability to open the eye during the examination. The use of a pinhole overcomes most refractive errors if glasses or contact lenses are not available. A subjective evaluation is often helpful. This may include noting the inability to count fingers or perceive light at close range.
Ocular movements are important in patients suspected of a fracture of the orbital wall to determine if muscles have been entrapped. Muscle restriction and diplopia should be noted. Examination may be difficult if swelling is present.
Triage Pointers for Emergent Conditions
Penetrating ocular injuries
It is imperative not to touch or manipulate the eye. If the penetrating object is present, it should be left alone because its removal may cause further herniation of the eye contents. The patient should be instructed not to eat or drink because surgery is often required to repair the eye. It is important to advise the patient to attempt not to strain, cough, blow his or her nose or bend over before getting treatment. Do not apply a pressure patch; however, a shield can be placed over the eye to provide protection.
Non-penetrating ocular injuries
Causes of blunt trauma to the eye include being hit with a ball, fist or surfboard. Examination can be difficult in the presence of lid edema, and care should be taken when examining the patient. Blunt trauma can produce hyphema, traumatic iritis and a dilated pupil, ruptured globe, dislocation of the lens, retinal hemorrhage and/or fractures of the orbit.
Regardless of the nature of the chemical injury, immediate, copious irrigation of the eye is essential to limit eye damage.
Acute angle-closure glaucoma (AACG)
The patient may complain of severe nausea and vomiting, extreme ocular pain, headache and blurred vision. The patient may be experiencing a migraine headache, or these symptoms may indicate an episode of AACG. AACG occurs when the IOP increases dramatically due to an anatomical blockage of the aqueous drainage from the eye, resulting in ocular and systemic complications. Patient history will provide several clues to assist in diagnosing this condition.
Typically patients with this condition are older than 50 years, are more often women, are hyperopic and have a family history of AACG. The patient will often notice a significant and rapid decrease in visual acuity, and the cornea will be hazy in appearance. This condition is almost always monocular. In patients with this condition, the eye will be injected (red eye) and the pupil mid-dilated.
Photophobia is a common sign and symptom associated with ocular emergencies, such as hyphema caused by trauma, iritis, keratitis, chemical burns, corneal abrasions, foreign bodies and ulcers.
Foreign body sensation with inability to open the eye
Patients with foreign bodies in the cornea and conjunctiva commonly experience sudden and severe pain. Their vision usually remains intact. Other conditions that may present with signs and symptoms of foreign body sensation include:
- Dry eye
- Corneal abrasion
- Inturned eyelash (trichiasis)
- Corneal foreign body
- Foreign body under eyelid
- Recurrent corneal erosion (spontaneous)
Orbital cellulitis is a rare but potentially life-threatening condition that exhibits both ocular and general symptoms. The typical patient is younger, with general malaise and rapid onset of fever. Commonly the eye is proptotic, and the patient describes severe pain on ocular movements. The eye and surrounding tissue are chemotic, and visual acuity may be poor.
Retinal detachment (RD)
Patients with RD frequently describe symptoms of “flashes” and “floaters.” Longstanding floaters can be due to relatively benign conditions and do not represent an emergency situation. Patient history is vital in determining the diagnosis.
Recent, progressive onset of symptoms may indicate an RD. The “flashes” and “floaters” typically increase over a short period of time, and the patient often describes a “cloud” or “web” over his or her vision. The patient may report a recent history of ocular trauma or surgery. Incidence of RD increases with age and level of nearsightedness.
Systemic disease such as diabetes can cause retinal pathology, increasing the risk of RD. Visual acuity may not be reduced if the detachment is peripherally located. However, if vision has decreased, it is likely that the central retina is affected, increasing the importance of immediate treatment. Pupil examination results are usually normal.
- Understanding common ocular emergencies aids prompt diagnosis and referral, which can have a significant impact on patient prognosis.
- Useful workup includes history, observation, pupil examination, ocular movements if a fracture is suspected and documentation of vision.
- It is important to document onset and duration of symptoms, current ocular conditions and immediate ocular history, particularly of trauma.
- An extended history of the present illness includes a chief complaint and four of the following elements:
- Location — Associated signs and symptoms
- Quality — Timing
- Severity — Context
- Duration — Modifying factors
- Penetrating eye injuries, orbital cellulitis and RD require immediate attention.
- Copious eye irrigation is the initial treatment for all chemical burns.
- AACG is confirmed by IOP testing and gonioscopy.
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About the author: This article originally appeared in the September 2010 issue of Techniques. It was written by Academy Coding Specialist Kim M. Ross, OCS, CPC.