Emergency Eye Triage

• Emergency eye triage involves rapidly assessing and prioritizing patients presenting with ocular complaints to ensure timely and appropriate management.
• Effective triage minimizes delays in treatment that could lead to vision loss or other serious complications.

Initial Assessment

• Triage begins with a focused history and brief examination to determine the urgency of the patient's condition.
• Key aspects include:
  • Visual acuity: Assessing the patient's vision in each eye.
  • Pain level: Determining the severity and nature of ocular pain.
  • Mechanism of injury: Understanding how the injury occurred (if applicable).
  • Current medications and allergies: Identifying any relevant medical history.

Triage Categories

• Immediate: Sight-threatening conditions requiring immediate intervention.
• Urgent: Conditions requiring evaluation and management within a few hours.
• Semi-urgent: Conditions needing attention within 24 hours.
• Non-urgent: Conditions that can be managed in a routine setting.

Immediate (Sight-Threatening) Conditions

• Central retinal artery occlusion (CRAO): Sudden, painless vision loss.
• Retinal detachment: Sudden onset of floaters, flashes, or a curtain-like visual field defect.
• Chemical burns: Ocular exposure to acids or alkalis.
• Penetrating ocular trauma: Any injury that breaches the globe.
• Acute angle closure glaucoma: Sudden onset of severe eye pain, blurred vision, halos around lights, nausea, and vomiting.
• Endophthalmitis: Intraocular infection, often after surgery or trauma, characterized by pain, redness, and vision loss.
• Optic neuritis: Inflammation of the optic nerve causing vision loss and pain with eye movement.
• Giant cell arteritis (GCA): Systemic vasculitis that can cause sudden vision loss, headache, and jaw claudication.

Urgent Conditions

• Corneal ulcer: Open sore on the cornea, often with pain, redness, and photophobia.
• Iritis/uveitis: Inflammation of the iris or uveal tract causing pain, redness, and light sensitivity.
• Traumatic hyphema: Blood in the anterior chamber of the eye due to trauma.
• Orbital cellulitis: Infection of the soft tissues around the eye, causing swelling, redness, and pain.
• Herpetic eye disease: Ocular infection caused by herpes simplex or herpes zoster virus.
• Acute dacryocystitis: Infection of the lacrimal sac, causing pain, redness, and swelling near the inner canthus.

Semi-Urgent Conditions

• Conjunctivitis: Inflammation of the conjunctiva (pink eye), causing redness, itching, and discharge.
• Hordeolum/chalazion: Localized infection or inflammation of the eyelid.
• Corneal abrasion: Scratch on the cornea, causing pain and light sensitivity.
• Subconjunctival hemorrhage: Bleeding under the conjunctiva.
• Blepharitis: Chronic inflammation of the eyelids.

Non-Urgent Conditions

• Dry eye syndrome: Chronic lack of sufficient lubrication and moisture in the eye.
• Allergic conjunctivitis: Eye inflammation due to allergens.
• Pinguecula/pterygium: Common, non-cancerous growths on the conjunctiva.

Key Decision Points

• Visual Acuity:
  • Sudden loss of vision is always an emergency.
  • Reduced acuity requires prompt evaluation to determine the cause.
• Pain:
  • Severe pain is a red flag, especially if accompanied by other symptoms.
  • Pain out of proportion to physical findings suggests serious pathology.
• Redness:
  • Diffuse redness can indicate conjunctivitis, iritis, or angle closure.
  • Localized redness may suggest hordeolum, chalazion, or dacryocystitis.
• Discharge:
  • Purulent discharge suggests bacterial infection.
  • Watery discharge is common in viral or allergic conjunctivitis.
• Trauma:
  • Rule out globe rupture in any case of ocular trauma.
  • Assess for foreign bodies and orbital fractures.

Examination Techniques

• Visual Acuity Testing: Use a Snellen chart or near vision card.
• Pupillary Examination: Assess size, shape, and reactivity to light.
• Extraocular Movements: Check for pain or limitation of movement.
• Slit Lamp Examination: Evaluate the cornea, anterior chamber, and lens.
• Fundoscopy: Examine the retina, optic nerve, and blood vessels.
• Intraocular Pressure Measurement: Use tonometry to assess for glaucoma.

Management Principles

• Immediate Conditions:
  • Call ophthalmology immediately.
  • Provide supportive care (e.g., pain management, antiemetics).
  • Protect the eye with a shield if there is a risk of injury.
• Urgent Conditions:
  • Prompt referral to ophthalmology.
  • Initiate treatment as directed by the ophthalmologist.
  • Monitor the patient closely for any changes in condition.
• Semi-Urgent Conditions:
  • Schedule an appointment with an ophthalmologist or optometrist within 24 hours.
  • Provide symptomatic relief (e.g., artificial tears, warm compresses).
• Non-Urgent Conditions:
  • Schedule a routine eye exam.
  • Provide education on self-care measures.

Special Considerations

• Pediatric Patients:
  • Children may have difficulty articulating their symptoms.
  • A thorough examination may require sedation or restraint.
  • Consider non-accidental trauma in cases of unexplained injury.
• Contact Lens Wearers:
  • Suspect corneal ulcer or keratitis in patients with red, painful eyes.
  • Instruct patients to remove their lenses and bring them to the evaluation.
• Immunocompromised Patients:
  • Higher risk of atypical or severe infections.
  • Consider opportunistic infections.
• Elderly Patients:
  • May have multiple comorbidities that complicate the evaluation.
  • Consider giant cell arteritis in patients with new-onset vision loss and headache.

Documentation

• Document all findings in a clear and concise manner.
• Include:
  • Chief complaint
  • History of present illness
  • Visual acuity
  • Pupillary examination
  • Extraocular movements
  • Slit lamp findings
  • Fundoscopic findings
  • Intraocular pressure (if measured)
  • Triage category
  • Management plan

Potential Pitfalls

• Misdiagnosis: Failing to recognize sight-threatening conditions.
• Delay in Treatment: Prolonging the time to definitive management.
• Inadequate Pain Control: Not addressing the patient's pain adequately.
• Failure to Obtain a Good History: Missing important clues about the diagnosis.

Ethical Considerations

• Patient Autonomy: Respecting the patient's decisions about their care.
• Beneficence: Acting in the patient's best interest.
• Non-Maleficence: Avoiding harm to the patient.
• Justice: Ensuring equitable access to care.

Conclusion

• Effective emergency eye triage requires a systematic approach to assess and prioritize patients with ocular complaints.
• Prompt recognition and management of sight-threatening conditions can prevent permanent vision loss.
• Continuous education and training are essential to maintain competence in emergency eye triage.

Emergency eye triage involves rapid assessment of patients with ocular complaints to ensure timely management. Effective triage minimizes delays in sight threatening conditions. Triage begins with a focused history and brief examination to determine the urgency of the patient's condition.