In this episode of Inside Intrepid, Chris Kruthoff, OD, FAAO, Alison Bozung, OD, FAAO, and Patrick Scott, OD, PhD, FAAO, discuss ocular emergencies and, more specifically, how clinicians can prepare for them and identify eye problems that require immediate attention. They also explain how to determine which specialists emergency patients should be referred to.
Dr. Kruthoff practices in an OD/MD private practice in the Minneapolis suburbs with a focus on treating glaucoma, cornea, and surgical comanagement. Dr. Bozung is a clinical associate professor at Byers Eye Institute at Stanford University and serves as director of the urgent care service. Dr. Scott is at UofL Physicians - Eye Specialists in Louisville, Kentucky, where he serves as an associate professor and clinician-scientist-educator in the Department of Ophthalmology and Visual Sciences at the University of Louisville School of Medicine.
Managing ocular emergencies and urgencies: fast facts
- Certain ocular emergencies, such as sudden vision loss, diplopia, severe pain, and neurologic or pupillary changes require immediate evaluation.
- Some eye emergencies need additional medical expertise. In these situations, it may make sense to refer patients to a specialist, such as a neurologist, instead of an ophthalmologist.
- Ocular emergencies aren’t always obvious. Seemingly benign symptoms can sometimes point to a more serious disease.
- Optometrists can better prepare for rare emergencies by participating in continuing education (CE) and building professional relationships with other medical specialists.
Deeper dive: Managing ocular emergencies and urgencies
When people experience sudden vision changes or persistent eye pain, they often visit the nearest emergency room to figure out what’s causing their symptoms. But research shows nearly a quarter of these ocular-related emergency room (ER) visits end up with a diagnosis for a non-emergent condition.1
Because ocular emergencies are relatively rare and their presentations vary from patient to patient, separating urgent cases from routine complaints is one of the more demanding judgment calls in practice.
Most urgent-seeming presentations are not vision-threatening. In a nationally representative US analysis, 79% of outpatient visits and 70% of emergency department visits for eye pain did not result in a primary diagnosis of a vision-threatening condition.2
Here’s what you can do to improve diagnostic accuracy and assist your emergency patients.
Recognize emergency symptoms that can’t wait
Not all optometrists have extensive emergency experience, but Dr. Kruthoff, Dr. Bozung, and Dr. Scott all agreed that certain symptoms should cause clinicians to drop everything and move quickly.
Some of the major red flags they say require emergency triage include:
- Sudden vision loss
- Sudden diplopia
- Severe eye pain
- Severe headaches
- Pupil changes
- Ptosis or other neurologic symptoms
- Symptoms that develop after a recent surgery
- Symptoms triggered by chemical exposure
The doctors recommend that all staff members responsible for handling phone calls or patient intake should be aware of these symptoms and know to escalate them for same-day evaluation. Even though not every emergency is vision-threatening, these symptoms could be, so it’s better to be safe than sorry.
“I would always rather over-call something than under-call it, right? Because the worst-case scenario if you over-call it is [that] it ended up being nothing.”
Don't dismiss subtle findings
Unfortunately, not every ocular emergency is obvious. Sometimes, subtle warning signs can indicate equally serious issues, so clinicians must rely on their training and gut. Severe or unusual headaches are a good example.
Dr. Bozung shared the story of two patients who presented with symptoms of what she initially thought were migraine aura. However, upon further inspection, one patient had a brain bleed, and the other had a stroke.
These cases illustrate just how challenging it can be to tell the difference between a benign condition and one that’s life-threatening. But if there’s any doubt, all three doctors said you shouldn’t be afraid to order additional tests or refer the patient out.
Know exactly where to refer your emergency patients
The doctors then discussed another common challenge: knowing where to refer emergency patients to. You might assume the obvious answer is an ophthalmologist or other eye specialist, but in reality, there’s much more nuance.
For instance, Dr. Kruthoff brought up central retinal artery occlusion (CRAO), sometimes called a “stroke of the eye.” An inexperienced clinician might refer a patient with CRAO to a retina specialist, but the appropriate destination is an emergency department for stroke workup, ideally at a comprehensive stroke center.
Another scenario the doctors discussed was a post-surgery cataract patient with endophthalmitis. A clinician without the necessary training might refer them back to the original cataract surgeon, but a retina specialist would make more sense as injections or surgery are necessary and time is of the essence.
The same can be said for open-globe injuries. Depending on where the injury is, these patients may need to see a retina or corneal specialist. Choroidal melanomas also require very specialized care.
Drs. Kruthoff, Bozung, and Scott acknowledged that a patient’s location and the time of day can significantly affect referral recommendations. After all, certain specialists, like ocular oncologists, aren’t always available or may have significant wait lists. Still, if you have access to an appropriate specialist, referring your patient to them is the best option.
“If it’s a corneal injury, ideally you want to get them to a cornea specialist … If it’s posterior to the cornea, ideally you want to get them to a retina specialist. But if it’s at night or on the weekend, [you have to get them] to whoever is available.”
Be prepared for rare emergencies
The doctors noted that many optometrists don’t see emergencies, especially when they don’t work in emergency-type settings. Even so, they shared several things clinicians can do to stay informed.
Dr. Scott recommended:
- Participating in continuing education
- Attending industry conferences and grand rounds
- Reading current literature
Similarly, Dr. Bozung suggested leaning into your professional network. For example, if a complex case walks through your door, you can reach out to a colleague and ask for their professional opinion.
“My biggest pearl is to be okay asking for help. No one knows everything.”
She also encouraged audience members to establish emergency protocols for their practices and team members, noting that, “how many flights have you been on where your airplane landed in the water … and you had to use the life jackets? None. Zero. How many flights have you been on where they talked about that and they prepared you for it? Every single flight. So, be ready for those situations, even though they might not ever happen.”
When an emergency arrives, don’t panic and be thorough
Emergency situations can be stressful and they require prompt action. Dr. Kruthoff said these dynamics can make it easy to feel overwhelmed, so much so that clinicians may get distracted or miss small details.
To prevent this from happening, he recommends taking a deep breath and doing what all optometrists are trained to do. Complete a thorough evaluation and follow the evidence.
What this looks like will depend on the situation, but Dr. Kruthoff says you can learn a lot from the standard parts of an ocular workup:
- Pupil exams
- Extraocular movements (EOM)
- Visual field testing
- Slit-lamp examination
- Intraocular pressure measurements (IOP)
- Dilation when appropriate
The goal is to identify the problem as quickly as possible to preserve the patient’s vision and ocular health.
At the end of their conversation, the doctors reemphasized the importance of recognizing emergency red flags and understanding when prompt attention is essential to preserving eyesight. By staying prepared, following a thorough evaluation process, and knowing when to ask for help, you and your team can be better prepared to handle ocular emergencies when they arise.
“You have to have those diagnoses, those oddities in the back of your mind even though you may not be seeing [them] very often. You have to have a workable model. You have to have a protocol in place.”
This article was written by Chad Birt based on the video with Drs. Bozung, Kruthoff, and Scott.
