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«Ophthalmology Guidelines for the Emergency Department Revised March 2012 Department of Ophthalmology Table of Contents Introduction 1 Referral ...»

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Ophthalmology Guidelines for the

Emergency Department

Revised March 2012

Department of Ophthalmology

Table of Contents



Referral Guidelines


Referral Categories


Driving to Ophthalmology Appointments


Patients Known to Ophthalmology


Contacting Ophthalmology


Contacting Winnipeg Ophthalmologists Who Take Call 5 On Call Ophthalmologist in Brandon 6 Contact Details for Retina Specialists 7 Contact Details for Other Ophthalmologists 8 Management Guidelines 9 Chemical Injuries 9 Visual Phenomena 11 The Chronic Red Eye 12 The Acute Red Eye 13 Ocular & Peri-Ocular Pain 17 Blurred Vision & Loss of Vision 18 Orbital & Peri-Orbital Swelling 20 Eyelid and Lacrimal Pathology 21 Diplopia 22 Pupils 23 Trauma 23 Specific Paediatric Ophthalmic Presentations 29 Appendices 30 Triage Guidelines 30 Guidelines for the ED revised March 2012 Department of Ophthalmology Minimal Standards of Documentation 30 Visual Requirements for Driving 31 Eye Patches and Eye Shields 32 Use of Eye Drops and Eye Ointments 33 Everting the Upper Eyelid 34 Analgesia for Painful Eyes 35 Slit Lamp Basics 35 Using a Tonopen 39 Using an iCare Tonometer 41 Image Gallery 42 Guidelines for the ED revised March 2012 Department of Ophthalmology Introduction This document has been compiled by the Department of Ophthalmology to assist emergency physicians in the management of patients presenting with ophthalmic complaints.

It is not intended to be a comprehensive text on ophthalmic emergencies, but rather provide reasonable guidelines for acute management and referral.

The first sections give advice on how and when to refer patients, how to deal with patients who have perviously been seen by an ophthalmologist and contact details for the ophthalmologists who take call. The latter half details common presentations, recommendations for management in the Emergency Department and how urgently they should be referred.

A gallery of representative images has also been included for reference.

It is our intention to update this document to reflect current knowledge and make it as useful as we possibly can. As it is intended to be viewed electronically, hyperlinks have been placed throughout the text to aid navigation. If you have suggestions on how the guidelines can be improved then please email Dr Ian Clark at iclark@hsc.mb.ca No part of this document may be reproduced without the authors’ permission.

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Referral Guidelines The purpose of these guidelines is to provide emergency physicians with easy access to relevant information that will aid accurate diagnosis and appropriate management. Whilst there are some conditions that will present to the ED that do not need to be seen by ophthalmology, we understand that the diagnosis is not always clear and we are happy to help out as needed.

The ophthalmologists who take call in the city usually have early morning hospital or office responsibilities. Their on call usually lasts somewhere between 72 & 168 hours (3 to 7 days). As such, it is greatly appreciated if calls between 11pm and 7am can be avoided unless they are emergent.

All referrals require a phone call to the on call ophthalmologist. Referrals cannot be made by fax (although a faxed consult containing your details and the patient’s demographics will usually be requested).

During office hours the calls will often be taken by an assistant in the ophthalmologist’s clinic. The assistant will be able to arrange an appointment and provide details of where to send the patient and their documentation. If an assistant is taking the calls then you can ask to speak to the ophthalmologist if you need medical advice on how to deal with your patient.

NB Never send an unstable patient to ophthalmology. Patients are often seen in private offices where there are no facilities to care for unstable patients. If the patient has other problems that preclude safe transfer then be certain to discuss this with the ophthalmologist so that appropriate arrangements can be made.

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Referral Categories

Throughout this document reference will be made to 2 categories of eye emergency:

Emergent and Routine:

• Routine: the majority of conditions presenting to an ED fall into this category. These referrals do not need be made in the middle of the night (between the hours of 11pm and 7am). This category does include pathology that can be very distressing for the patient (such as corneal abrasions and arc eye) but seeing such patients in the middle of the night will have no bearing on their outcome.

• Emergent: these referrals justify an immediate call to the ophthalmologist regardless of the time of day. There are relatively few conditions that warrant an emergent referral.

The following conditions warrant emergent referral:

Acute angle closure glaucoma.

Suspected central retinal arterial occlusion with onset in the preceding 4 hours.

Serious chemical injuries (especially lime).

Suspected endophthalmitis, especially in a patient with a history of a recent intraocular surgery or intraocular injection.

Suspected globe rupture or penetrating eye injury.

Suspected intraocular foreign body.

Third cranial nerve paresis - needs emergent referral to neurosurgery if there is evidence of an intracranial aneurysm.

Driving to Ophthalmology Appointments Pupil dilation is essential for a comprehensive eye examination. Some patients may not need their pupils dilated at an initial assessment (e.g. with problems affecting the ocular surface) but if fundus pathology is suspected then patients will definitely need to have dilating eyedrops.

These eyedrops blur patient’s vision and they should not drive until the drops have worn off (between 2 & 6 hours). It is helpful if you advise patients about this, particularly if there are suspicions of retinal pathology, so that they can arrange alternative transportation.

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Patients Known to Ophthalmology If the patient is seen during office hours and they are known to ophthalmology then it may be more appropriate to refer them to their own ophthalmologist who will have records from their previous visits.

Please be guided by the following recommendations.

During office hours:

• Recent surgical procedures: you should first contact the patient’s own ophthalmologist

• Recurrence of a condition that was treated by an ophthalmologist in the preceding 12 months: the referral should go to their treating ophthalmologist

• An emergent problem: refer immediately to the on call ophthalmologist

• The patient should be referred to the ophthalmologist on call for the day if:

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the patient is presenting with a recurrent complaint but they have not seen their ophthalmologist for over 12 months

After hours or on the weekend:

If you feel that there is an urgent change in a patient’s condition then please refer to the guidelines below and consult with the on call ophthalmologist as appropriate.

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Contacting Ophthalmology You will be able to find out which ophthalmologist is taking call by contacting the Misericordia Hospital switchboard on 774 6581. They will be able to connect you to the appropriate number or you can call the appropriate office during business hours (numbers below).

Please note that patients may be seen at the ophthalmologist’s office or on the Eye Ward (Cornish 3 North) at the Misericordia Hospital. Please be sure to clarify where the patient should go when you talk to the ophthalmologist or their assistant.

If patients are asked to attend the Misericordia they should first go to patient registration (easily found through the entrance to Urgent Care).

Contacting Winnipeg Ophthalmologists Who Take Call The table below provides the office address, telephone and fax numbers for the ophthalmologists who take general call.

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On Call Ophthalmologist in Brandon There is only one ophthalmologist in Brandon and he takes call roughly 2 weeks out of each month. When he is not on call the ophthalmologist in Winnipeg should be contacted about emergencies. Call the switchboard at Brandon Regional Health Centre on 204 578 4000 to have them direct your call appropriately.

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Contact Details for Retina Specialists The ophthalmologists who specialize in retinal disease operate a separate 1 in 4 on call rota. They should only be contacted directly about patients who are already under their care or if you feel certain that your patient has retinal pathology that justifies a referral to the on call retina specialist.

In general, patients will usually be referred to retina after having been seen by the on call ophthalmologist. Note that symptoms suggestive of a posterior vitreous detachment or retinal detachment should be referred to the on call ophthalmologist for screening.

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Contact Details for Other Ophthalmologists If your patient has recently seen an ophthalmologist who does not take call and you feel it is appropriate to refer the patient back to their care then you can find their contact details below.

Please refer to “Patients Known to Ophthalmology” for details about such referrals.

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Management Guidelines The following section provides advice on how certain common ophthalmic complaints may be appropriately managed by Emergency Physicians. These guidelines have been compiled by the Department of Ophthalmology in Winnipeg and are therefore in line with local policy and procedures.

Chemical Injuries

• Timing is critical. The longer the exposure, the greater the potential for damage (chemicals gradually penetrate the structures of the eye so it will take a great deal more time and fluid to effectively wash out chemicals after a prolonged exposure).

• Alkali injuries are generally worse than acids - they penetrate the eye causing liquefactive necrosis.

• Liquids are more easily irrigated from the eye so they tend to cause less damage.

• Powders and other solids can be retained under the lids or deep in the conjunctival fornices. They are therefore harder to remove and much more likely to cause serious damage than liquids. Lime is a common culprit that is particularly harmful as patients will often have retained clumps that slowly dissolve causing devastating ocular surface pathology.

• After a chemical injury there will usually be loss of some or all of the corneal epithelium (visible with fluorescein staining) and the eye will usually look very injected. However, more sinister sign is when the white of the eye loses its vascularity. This is leads to ocular ischaemia and is a sign of a more serious injury.


• All patients with chemical injuries should be triaged emergently and have their tear film pH checked as early intervention will prevent ongoing damage to the eye.

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• Tear film pH should be tested with universal indicator paper before putting any eye drops in the eye (drops may not be pH neutral). This is rarely a problem as the eyes are usually tearing so the paper can be touched to the lower lid margin to wet it.

If universal indicator paper is not available then there is a pH test on the standard ‣ urine dipstick that can be cut off and used.

The injury is more serious when the pH is further from the normal value of 7.5 ‣ (meaning that irrigation will need to be performed for longer)

• After checking the pH it will be necessary to use topical anesthetic to relieve blepharospasm.

• If the injury involved solids or powders then every attempt should be made to remove retained particles. This can be done using a Ringer’s lactate irrigation (or normal saline if Ringer’s is not available) and/or a moist cotton-tipped applicator (with liberal use of topical anesthetic).

Eversion of the upper lid should always be attempted to check for particles.

Note that the superior fornix is quite deep and particles can be hard to detect.

Several “sweeps” of the upper fornix should therefore be attempted (with a moist cotton-tipped applicator) to try to clear any particles that may be lodged there. Ask patients to look down when sweeping the upper fornix and look up when sweeping the lower fornix.

• After checking for retained solids (when relevant) the eye should be irrigated immediately & liberally with Ringer’s lactate (or normal saline if Ringer’s is not available).

A Morgan lens (www.morganlens.com) is ideal for irrigation otherwise the lids can be held open with a speculum or fingers. Have the patient look around whilst irrigating and be sure to direct some of the fluid into the lower and upper fornices as well.

• Irrigation should also be performed if the pH is normal - irritant chemicals can still cause damage and these should be thoroughly washed out (although 1 bag of fluid will usually be sufficient in such cases).

• The volume of fluid required to neutralize the pH will vary according to the pH of the chemical and the length of exposure. The pH should be retested 5 or 10 minutes after stopping irrigation. This allows the tear film time to equilibrate with the pH of the eye. If

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the pH remains more than 0.5 away from normal (7.5) then further irrigation is advisable. 8 to 10 liters may be needed if the pH is very acidic or alkaline on presentation.

• A cycloplegic agent may be used, such as gt. homatropine 2% (not phenylephrine as it vasoconstricts). This relieves ciliary spasm and helps with pain.

• Start an antibiotic eye ointment such as erythromycin (avoid gentamicin). Never give topical anesthetic eye drops to patients for use at home.

• Routine referral unless there is ocular ischaemia or other sinister signs.

Visual Phenomena This refers to “seeing things” that the patient knows are not really there.

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