Bnar Massraf
East of England
Introduction
Most local pathways triage eye presentations from the Emergency Department (ED), directly to Eye Casualty. However, a smaller number are managed, at least initially, by the ED team. This can include patients with polytrauma or that are systemically unwell. Some smaller departments do not even have on-site out-of-hours Ophthalmic services. A proportion of these presentations are true emergencies, where any delay to recognition or management could cost a patient their sight.
Previous articles discuss several of the conditions covered here, however, this guide to emergency presentations answers the question on what a Foundation doctor’s responsibility involves in management and referral. Using the current Moorfields Eye Hospital A&E emergency guidelines, five presentations will be discussed (1). For each of these conditions, the foundation doctor working in the ED department should know immediately what action should be taken and the point at which escalation is necessary. The goal is not making Ophthalmologists out of foundation doctors but rather draw the line on where their own responsibility begins and ends.
It is important to note that the foundation doctor would provide a basic examination in any presenting complaint involving the eye for proper assessment and handover. This would include basic inspection (redness, discharge, clouding), pupillary reflexes (RAPD), eye movements, visual acuity (including colour vision) and fundoscopy (2). This is very achievable in an emergency department with a pen torch, ophthalmoscope and Snellen chart. Slit lamps can also be found nearby most of the time.
As a resident doctor, the management of these conditions described below must be safely initiated through discussion with a senior. In the emergency department, this would be in the form of the ED registrar or consultant, in parallel with Ophthalmology input.
Chemical Injury
This is the only presentation on this list where treatment needs to start before, not after, assessment. This warrants immediate irrigation, for any substance contacting the eye. Guidance for this states to irrigate with 0.9% saline, making sure to also evert the eyelids to include the fornices (1). This can be done easily using a cotton bud on the upper/lower tarsal plate and pulling the lid over with your fingers holding their eyelashes (3). This is done until the pH normalises to 7.0, which can take up to 20L of saline to return pH to normal physiological levels (4). Oral analgesia may also be given alongside (1). This should not wait for senior review or even assessment with a slit lamp. Referral happens once the eye is neutral for grading and follow up (1).
Acute Angle-Closure Glaucoma (AACG)
Acute angle-closure glaucoma typically presents as a red eye with a larger, non-reactive pupil with pain, blurred vision, headache and nausea (1). This must be referred urgently and warrants a same-day review (1).
It is important to note AACG may be missed as headache or nausea/vomiting can dominate the clinical picture in the early stages, triggering medical or neurological assessments before the eye can be properly examined.
The doctors who suspect AACG should not wait for specialists to start management. If required, medications such as analgesia and an antiemetic can be given straight away. To reduce intraocular pressure (IOP), topical Pilocarpine, beta blockers (e.g. Timolol), steroids and systemic Acetazolamide are given (5). Pilocarpine should be deferred until IOP is below 40mmHg as it won’t respond due to ischaemia of the pupillary sphincter (6).
Patients should also be postured to be supine to help open the angle (7). For example, what would be beyond the foundation doctor’s remit is prescribing medications such as Mannitol, which increases the osmotic gradient between the blood and the eye and definitive management such as laser peripheral iridotomy (7).
Central Retinal Artery Occlusion (CRAO)
This can present as sudden, painless loss of vision in one eye. Pupil reflex will show RAPD. On fundoscopy, a pale retina with the classic ‘cherry red’ spot can also be noted (8). An undilated eye in a busy emergency department can make fundoscopy more daunting than usual, but this should not delay action. A thorough history paired with a RAPD alone should raise suspicions and trigger urgent referrals to both Ophthalmology and the stroke team (if within 4 hours of onset) (8).
Bloods must also be taken at the time of assessment– including FBC, CRP, ESR, glucose, U+E, TFT, lipid studies and HBA1c (8). In CRAO, ocular massage is often taught as a bedside intervention while awaiting review, but it should be noted that robust evidence regarding its ability to dislodge clots is lacking (9). This can still be used as a low-risk adjunct but not delay referral.
Giant Cell Arteritis (GCA)
Like AACG, GCA can initially present as a headache. Temporal pain, scalp tenderness, jaw claudication and visual disturbance may require direct questioning during a history to establish. Fundoscopy here can show optic disc swelling and waxy pallor (1). Because the risk is irreversible bilateral visual loss, the foundation doctor should act ahead of review from Ophthalmology or Rheumatology. On clinical suspicion alone, bloods (e.g. FBC, CRP, ESR) are sent off and high dose steroids are given (oral Prednisolone 60mg) without confirmation from a biopsy or specialist review (1). The most avoidable error regarding GCA would be delaying steroids to await specialist review.
Orbital Cellulitis
Swollen eyelids cover a wide range of acuity, from self-limiting chalazions to genuine emergencies. Distinguishing between these is core to a foundations doctor’s skill. This would be establishing swelling without systemic illness, diplopia, proptosis, ophthalmoplegia, reduced colour vision or optic nerve involvement. In these cases, preseptal cellulitis can be managed with oral antibiotics and safety netting with follow up (1).
Presence of any of these features would change the diagnosis to orbital cellulitis and drastically change management and acuity. Patients would be admitted as emergencies with bloods, cultures and conjunctival swabs sent off straight away with IV antibiotics (as per local guidelines) started as soon as possible. Extent of cellulitis and eye movements should be documented with joint referral to Ophthalmology and ENT (1). Urgent CT head with orbits can also be ordered. The foundation doctor’s responsibility here would be identifying these red flags at first assessment as this could mean the difference in sending a patient home or admitting them for IV treatment and imaging.
Conclusion
What these presentations have in common is that the first useful action belongs to the foundation doctor, not ophthalmologists. Irrigating chemical injuries, starting steroids in GCA, recognising which eyelid swelling needs admission or referring sudden vision loss. This is core emergency medicine knowledge. None of these presentations require slit lamp expertise or specialist knowledge, but rather how to recognise these conditions, what action can be taken and how quickly to escalate.
Bibliography
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