As a first-year ophthalmology resident, you will see your fair share of eye emergencies. Some of these will require urgent surgical intervention. Use this checklist as a guide to give patients the best care in these stressful situations.
Make sure the patient takes nothing by mouth
- Once you have the inkling the patient may need surgery the same day, immediately tell him or her to stop eating and drinking. If it is a true emergency, you will not have the luxury of eight hours on an empty stomach.
- The anesthesiologist can make do with rapid-sequence induction using a fast-acting paralytic such as succinylcholine or rocuronium to prevent aspiration.
Take care of logistics
- The specific protocol for adding on an urgent, same-day case in the operating room varies from institution to institution. Each time you start working at a different institution, make sure to learn how things are done.
- Do not delay the necessary procedures: booking an eye OR, calling in the on-call eye team (if there is one) and notifying the anesthesiologist.
- Call the nearest eye bank immediately if you will need donor cornea or sclera for your case.
Assess and protect the open globe
- Gently check the Seidel test using sodium fluorescein. Beware of the possibility of a Seidel-negative wound in a ruptured globe. If the IOP is low enough, you may see no egress of fluid.
- If the globe has ruptured, make sure you start intravenous antibiotics, cover the eye with a fox shield and instruct the patient not to perform the Valsalva maneuver.
- Think about the possibility of a penetrating foreign body. Look for an entry and exit wound.
- Consider a very gentle B scan, especially if you have no view to the posterior segment and you suspect an intraocular foreign body.
- Ask the anesthesiologist not to use succinylcholine during intubation. (This risks expulsion of intraocular contents.)
Consider the possibility of extraocular injury
- In a trauma patient, consider that s/he may have more than eye injuries. For example, if the patient has neurological complications or facial trauma, you will want to consult another service before taking the patient to the OR for dedicated eye surgery.
- Get imaging of the face, orbits and head, if needed.
Obtain informed consent
- In most emergency situations, patients will have a poor, guarded and/or unknown prognosis. Set realistic expectations for the patient and/or guardian.
- If the globe has ruptured, let the patient know that your main goal is to close the eye and decrease the chance of endophthalmitis. The secondary goal is to preserve and improve vision.
Make sure the patient has social support
- Be sensitive that an unexpected need for emergency surgery is stressful and can potentially devastate a patient.
- If family is present, involve them in the discussion of diagnosis and prognosis. The patient will need their moral support and a ride home.
- Expect the unexpected in emergency situations. The better prepared you are, the less flustered you will be in the operating room.
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About the author: Olivia L. Lee, MD, is a cornea and uveitis specialist at UCLA and has been a member of YO Info’s editorial board since 2015. She is also the associate medical director of the Doheny Image Reading Center and the cornea fellowship director at the Doheny Eye Center.