Emergencies After Hours: OCT in the Eye-Only ER

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Optical coherence tomography (OCT) has come out of the workday setting and into the night. Doctors at New York Eye & Ear Infirmary (NYEE) of Mount Sinai Hospital in New York report that access to OCT in the hospital’s after-hours emergency eye clinic has led to timely diagnoses and vision-saving treatment. Other benefits included improved patient satisfaction and reduced physician stress.¹

The OCT system used in this study (iScan, Optovue) is described by the manufacturer as automated; it uses computerized voice directives in multiple languages to direct patient positioning and fixation. The technical training of the NYEE ophthalmology residents took less than 30 minutes, the authors said. “Automated OCT minimizes user training, allowing the technology to slip into this acute setting seamlessly,” said coauthor Rich­ard B. Rosen, MD, at NYEE.

Review of records. Over a period of 15 months, 202 patients (359 eyes) underwent automated OCT scanning in the hospital’s resident-run urgent eye care clinic. The most common complaint that prompted imaging was decreased vision (120, 59%), followed by flashes/floaters (32, 16%), then metamorphopsia, sco­toma, and pain.

Impact on patient care. The imaging system proved its worth in furthering rapid triage in appropriate cases, Dr. Rosen said. For example, OCT can be helpful in diagnosing subtle cases of CRAO without characteris­tic fundus findings and decreased vision. One patient had increased reflectivity of the inner retinal layers and a loss of definition on OCT, confirming a suspected diagnosis of reperfused CRAO. She was transferred to Mount Sinai’s main ER for a cardiovascular workup.

Impact on providers. Eighteen residents and seven fellows completed a survey about after-hours access to the imaging modality. Of the 25 participants, 21 felt that use of the automated OCT system improved patient satisfaction and reduced delayed or missed diagnoses, and 19 reported feeling less stress while using the sys­tem, as it reduced their uncertainty over subtle pathol­ogies. “Both patients and physicians benefited by the reassurance that the correct diagnosis and appropriate triage plan could be confidently implemented in such a setting,” Dr. Rosen said.

Critical caveat. This system was not effective in patients with a visual acuity of 20/400 or worse, as the device’s minimum vision requirement stipulates that patients should be able to find fixation cues without operator redirection.

Bottom line. Further study may reveal the utility of automated OCT in sight-threatening conditions such as an unusual presentation of acute retinal arterial occlu­sion requiring interventional radiology, Dr. Rosen said. Automated OCT “in an urgent care setting can be a powerful tool for triaging a variety of sight-threatening conditions that require immediate attention,” he said. The use of such a system “reduces the need to relegate this important diagnostic technology to workday set­tings where skilled operators are available.”

—Miriam Karmel

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1 Kaplan RI et al. BMJ Open Ophthalmol. 2019;4:e000187.

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Relevant financial disclosures—Dr. Rosen: Optovue: C.

For full disclosures and the disclosure key, see below.

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