Optometrists working in practice hold such an important role in the overall eyecare system whether you work in America, or in the UK where I work.
As newly qualified optometrists you have so many aspects of our profession to be up to speed on, as you develop your own style of practice and routines for how you deal with a whole variety of situations.
In this article, I want to highlight some of the urgent ocular emergencies, conditions and problems that patients may present with so that these will instantly sound an alarm bell in your clinical brain.
In optometry practice, we are open to just about every condition walking through the doors, and patients seek your opinion as the first port of call. There are some obvious ocular emergencies which don’t occur often, for example angle closure glaucoma, as these patients are in severe pain, are unwell generally so they make a direct line to hospital departments, but there are plenty of urgent conditions where optometry practice is the first point of contact.
There are several key scenarios to be aware of, which should raise a red-flag when they present:
- Loss of vision. Most patients with reduced vision tend to be gradual changes, due to conditions such as cataract or AMD. Any patient with a sudden or severe loss of vision should be viewed with suspicion and the cause investigated thoroughly. Causes can be varied, usually pertaining to the posterior segment – anterior ischaemic optic neuropathy, a venous or arterial occlusion, vitreous hemorrhage, retinal detachment, and the list goes on. You will notice that a number of these conditions have implications not just for the vision of the eye, but also the patients’ general health.
- Flashing lights and floaters – retinal detachment is worth a mention in its own right as it happens relatively often. Any onset of flashing lights, floaters with a shadow in the vision, particularly in a myope, must be treated as a retinal tear or detachment until proven otherwise. Time is of the essence with getting these referred out, particularly if the macula is still on, as the patient stands a good chance of the sight of the eye being saved with surgical intervention.
- Distorted vision – another condition which merits its own mention is wet AMD. Again, any older patient reporting a recent reduction in vision, with distortion should be treated as highly suspicious of wet AMD. Again this is important as early intervention with anti-VEGF injections can help save sight. Being able to recognize this with dilated funduscopy and OCT scanning if available is a really crucial skill.
- Red/painful eyes – we see a lot of red eyes which are fairly minor conditions and can be managed in practice, such as blepharitis and some forms of conjunctivitis. The skill here is in detecting the cases when there may something more serious at play. Symptoms such as a pain or ache within the eye, rather than superficial discomfort and photophobia might point towards an inflammatory cause which might need a referral. You need to develop a routine for assessing red eyes, which should include checking the anterior chamber for cells and flare, measuring IOP, checking under the eyelids, staining the cornea and checking for an ulcer. I once used the term ‘straight forward red eyes’ to one of my consultant colleagues, and they said that there is often no such thing.
- Corneal ulcers – again worth a mention in their own right. Either microbial keratitis, acanthamoeba or herpes simplex keratitis all require prompt treatment. The patient will be in pain, and the health of the cornea is at risk.
- Injury – a lot of these can bypass optometry practice but we do get foreign bodies, abrasions and occasionally chemical injuries. With chemical injuries – you must rule out an alkali burn which can be devastating to the eye – if this is the case, lots and lots of irrigation with saline as a first aid measure before getting the patient to ophthalmology if warranted. Some practitioners are comfortable with foreign body removal, but don't do anything which isn’t within your remit – anything which is deep in the cornea needs ophthalmology attention due to the risk of corneal perforation.
- Other symptoms - there are a host of other symptoms which can present and may be due to a serious underlying cause. Sudden onset of diplopia, particularly in young and otherwise healthy patients needs to be investigated. Headaches can be from a variety of sources and causes but always think of checking the optic nerve appearance and function, to rule out a serious finding such as papilloedema.
These are just designed to get you thinking about some of the scenarios which can arise – there is no way in the scope of a short article a detailed description of all possible ocular emergencies can be given, but hopefully this highlights some of the most common ones.
When you are developing your skills and experiences as an optometrist, don't be afraid to chat with colleagues when cases arise which you don't feel comfortable with. Get their advice, or call your ophthalmology department and seek their expertise. We are not expected to diagnose every condition that comes our way, as some conditions are rare, some require other investigations which are beyond our knowledge, but our role is to be thorough as clinicians, in taking a good history and applying the appropriate clinical tests. When you do see interesting pathology, there is no better learning experience. It is always good to take the opportunity to have a read around the topic when the condition arises.
Often the first person to encounter the patient when they present to practice are the reception and dispensing staff.
I have developed a really useful tool for practice staff, The Eye Safety Card, which essentially highlights some of the red-flag situations I have discussed above. The idea of this is to highlight to practice staff that these patients need to be seen by the optometrist urgently, rather than being offered an appointment several days or a week later, which might be risking the patients’ sight. These have proved really popular in the UK with uptake from optometry, general practitioners, and pharmacists. It can also be a useful reminder for optometrists of the main group of ocular emergencies.
This Eye Safety Card can be viewed and ordered at – www.Optometry-Evolution.com
Thanks for reading, and I really hope that you found this article useful.
About the Author:
Stanley Keys – Specialist Hospital Optometrist, Inverness, Scotland
Founder of Opometry-Evolution.com and Eye Safety Card.