Article Date: 9/1/2006

Eye Care STAT

Can your staff recognizeocular emergencies? This four-tier system will help them decide who needs to see you NOW.
By Phyllis L. Rakow, C.O.M.T., N.C.L.E.-A.C., F.C.L.S.A.(H), Princeton, N.J.

"I NEED to see the doctor right away — and I don't have an appointment." Your 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 you 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.

Your front-desk staff may not be trained for this sort of evaluation, but your assistants or technicians should be able to triage ocular emergencies and schedule patients accordingly. You can simplify their choices by dividing clinical presentation into four tiers: Urgent 1, Urgent 2, Priority and Routine.

Gathering Information

When performing the preliminary work-up on emergency patients, your technician should begin the triage process by recording patients' answers to these questions:

   • Which eye is involved?

   • How did it happen? (for injuries)

   • When did the symptoms start?

   • Was the onset sudden or gradual?

   • Are the symptoms constant or intermittent?

   • Did you use any eye drops or try to treat the problem yourself before contacting our office?

   • Did you go to the emergency room or your primary care physician before contacting our office?

   • Has the problem gotten better or worse?

Based on the answers to these questions and your staff's knowledge of the four triage tiers, they should be able to make appropriate decisions regarding scheduling. Of course, any uncertainty should prompt them to check with you. They should always use caution and schedule a patient as soon as possible, and be prepared to refer truly urgent cases to another doctor or a hospital emergency room.

Urgent 1: See Immediately

The following symptoms and ocular injuries are acute emergencies. You need to see these patients immediately:

Sudden loss of vision, flashes, floaters. Depending on the location, some patients with retinal detachments may describe a veil or curtain ascending on their field of vision, or loss of part of their visual field. Those with occlusions of the central retinal artery, branch artery or central retinal vein may suddenly lose all or part of their field of vision.

Not all patients who call with complaints of flashes or floaters will have a retinal tear or detachment, but it's critical to see them for a dilated examination as soon as possible to determine the cause of their symptoms.

• Sudden onset of double vision: In an adult, diplopia may be caused by a number of serious conditions, such as stroke, diabetes, thyroid disease, brain tumor, metastatic lesion, neurological problem or trauma. Patients sometimes describe double vision when they actually have a ghost image, resulting from uncorrected astigmatism or cataracts.

To determine if someone has true double vision, the staff should ask the patient to cover one eye to see if the problem disappears. If it does, the patient has true double vision, requiring immediate attention, but if the patient still sees a double image with one eye covered, the problem is a ghost image and can be addressed with a same-day appointment.

• Blood in the eye: A patient whopresents with a blood-filled eye may havea blackball hemorrhage or a hyphema, which require urgent
care, or a less serious subconjunctival hemorrhage. The third problem, caused by a break in one of the conjunctival blood vessels, can be very frightening to the patient. The blood becomes trapped under the conjunctiva and may take a week or two to be re-absorbed. While this is not a true emergency and doesn't require treatment, you must see these patients right away to determine where the bleeding is and rule out a more serious problem.

• Blunt trauma to the eye: Blunt trauma to the eye may cause a blowout or orbital floor fracture, possibly trapping the external muscles that move the eye and causing double vision. The retina also may be torn or detached. Although a black eye (hematoma) may seem like a common and not-too-serious injury, it can be very serious. There may be bleeding inside the eye's anterior chamber (hyphema) or posterior chamber (blackball hemorrhage), as noted above.

• Penetrating injury: When any object, such as a nail or a piece of glass, penetrates the eye, the injury is potentially sight-threatening and requires immediate treatment. Penetrating injuries often have a poor prognosis, but prompt treatment may prevent or limit loss of vision. Lid lacerations need immediate attention to restore the lid tissue to the original position and to prevent infection.

• Chemical burns: Your staff's immediate reaction to a patient with a chemical burn should be to tell him to irrigate the eye as soon as possible. This helps minimize destruction of ocular tissues, which can lead to permanent scarring and vision loss. Time is often a factor in patient outcomes. Be sure your staff understands that these patients should see you immediately.

Urgent 2: See Today

The following symptoms don't indicate acute emergencies, but patients should see you on the day they contact your office.

• Red eye: Many complaints of red eyes warrant a same-day appointment. Red eyes accompanied by discharge, tearing, itching, sensitivity to light, or swelling of the pre-auricular glands in front of the ears require attention within hours. These may be signs and symptoms of microbial conjunctivitis, keratitis or keratoconjunctivitis, which can be highly contagious.

When the cornea is involved, a patient may describe sharp, stabbing pain along with light sensitivity. There may be a ring of redness surrounding the cornea or a red area on the conjunctiva.

A red eye accompanied by intense pain, rainbow-colored halos, a cloudy cornea and blurred vision may indicate acute angle-closure glaucoma. This patient's IOP may be extremely high and must be brought under control immediately to prevent permanent damage to the eye. Once the IOP is under control, the patient will require treatment with a YAG laser.

• Lid problems: Lumps and bumps on the lids are most often caused by styes or swelling of the meibomian glands (chalazia), although malignant lesions do occur. Patients with lid problems may have blepharitis, an inflammation of the lid margin accompanied by redness, burning and scaliness around the lashes.

• Protrusion of an eye: Protrusion of one or both eyes, sometimes accompanied by double vision, may be caused by thyroid disease, tumors or pseudotumors.

• Contact lens discomfort: Patients need a same-day appointment if they complain of pain, redness, discharge or cloudy, foggy or steamy vision, tearing, sensitivity to light or the inability to remove a lens from the eye. Most other contact lens-related problems fall into the priority or routine tier. To schedule patients appropriately, have your assistant or technician ask contact lens wearers these questions:

   • What type of contact lenses are you wearing?

   • What care products do you use? (Ask patients who call in to bring the products with them.)

   • Do you fall asleep while wearing your contact lenses?

   • Did you accidentally fall asleep with them just before the symptoms began?

   • Were you around cigarette smoke, fumes or hair spray?

   • Do the lenses film up quickly?

   • Do they slide around on your eyes?

   • Do they slip under your upper lids when you blink?

Priority: See This Week

Some requests for "emergency" appointments come from patients who have experienced their symptoms for weeks or months. Although the underlying problem may be serious, a delay of a day or two probably won't affect the outcome. These priority problems should be scheduled within a few days.

• Contact lens adaptation: Patients who recently started wearing gas permeable lenses may experience normal adaptation symptoms, including watery eyes, lid irritation, difficulty looking up, intermittent blurring or excessive blinking. They need to be seen in a timely manner and reassured their symptoms are normal, but don't require an immediate appointment. Patients also can wait a few days if they have contact lens slippage or see blurring or distortion after lens removal.

• Slow disease progression: Patients who have experienced a gradual loss of vision in a quiet (uninflamed and painless) eye may have a cataract or macular degeneration. The condition won't progress significantly if the patient waits a day or two for an appointment. Patients with chronic open-angle glaucoma can be scheduled on a priority basis, as long as the elevated IOP isn't accompanied by pain, redness, severe headache, or seeing rainbows around lights. Patients with crossed eyes or amblyopia can wait for a priority appointment unless the double vision occurs suddenly.

• Lost or broken eyeglasses: Some patients want an emergency visit because they've lost or broken their eyeglasses. If they depend on their eyeglasses to drive, read or otherwise function, they should be seen the same week. Other priority-level problems include headaches and dry eyes; a droopy eyelid; a small, yellowish raised bump on the white of the eye (pinguecula); or burning and tearing that have been going on for a long time.

Routine: Make an Appointment

The final triage tier comprises problems involving everyday symptoms that may go away on their own or require some patient education. For example, patients with abnormal blinking, small floaters without flashes, slow changes in near or distance vision and complaints of ghost images or halos and starbursts around headlights and streetlights are candidates for a routine appointment. For contact lens wearers, routine complaints include dryness, fluctuations in vision with the blink, possible mixed lenses or difficulty with lens insertion and removal.

Handling the Front Lines

Triage systems originated on the battlefield, but they're essential at home, too. Your optometric assistants and technicians are the patient's link to you, and triage is a part of their primary responsibilities. You must teach them your preferences for handling ocular emergencies, from effectively screening patients for signs, symptoms and prior history to efficiently scheduling them for the best possible outcomes and most efficient workflow. It's important that your staff know how to question without diagnosing, and that they act with caution if they have any doubt.

Phyllis L. Rakow is Director of Contact Lens Services at the Princeton Eye Group in Princeton, N.J., and serves on the National Contact Lens Examiners Board of Directors.

Optometric Management, Issue: September 2006