It is a common scenario: a patient calls, stating they have scratched their eye and they would like to be seen as soon as possible because they are in pain. While the scratch itself may be minor and not a true ocular emergency, the situation certainly is from the patient’s point of view: They are in pain and they want the doctor to fix it. Of course, any optometrist would get this patient in as soon as possible, but once the patient is in the chair, what constitutes a true ocular emergency that requires emergent referral for further care?
The answer often depends on state regulations regarding what the optometrist can legally manage and what privileges are allowed for prescribing certain medications. The optometrist’s experience and comfort level managing the given pathology is also important to consider. However, the severity of the injury dictates which cases require referral for specialty care. Here are three hypothetical conditions with example cases to help differentiate what can be managed in the office from what requires an urgent or emergent referral.
Corneal Trauma: Is a scratched eye an emergency?
The patient presents with a recent history of scratching or hitting the eye, and complains of sharp pain and foreign body sensation, light sensitivity, and maybe even blurred vision. Examination reveals eyelid edema, conjunctival injection, and an epithelial defect of the cornea. The diagnosis seems straight forward. This patient has a corneal abrasion. But does this patient need a referral?
Treatment plan: The slit lamp examination should rule out an underlying corneal opacification (an infiltrate indicates infection or inflammation!), a lingering foreign body (evert the lids!), and corneal laceration or penetration. Additionally, measurement of the size and depth of the abrasion should be performed to help monitor the healing process. In the case of a simple abrasion, this patient can usually be managed in office following a few basic protocols.
Consider another patient with the same presentation, but this time examination reveals a corneal laceration. Careful slit lamp examination is required to exclude corneal penetration. There should be no evidence of anterior chamber shallowing in comparison with the fellow eye, and a negative Seidel test helps confirm a closed globe. If there is only a partial thickness laceration, does this patient need a referral?
Treatment plan: If the laceration is shallow and peripheral, it may be managed in office using similar protocols to corneal abrasion management. However if the laceration is central or presents with wound gape, it will require surgical suturing in the operating room to avoid excessive scarring and corneal irregularity. This will require an urgent referral to the local corneal specialist.
Consider a third patient who presents with the same history but examination reveals the presence of a penetrating ocular injury. The presence of anterior chamber shallowing, a peaked or irregular pupil, or wound leak indicates corneal penetration and the presence of an open globe. The patient may also present with decreased vision or low intraocular pressure.
Treatment plan: Once the diagnosis of an open globe is made, further examination and manipulation of the eye should be deferred until the time of surgical repair. Immediately protect the eye with a shield (not a patch!), and arrange for surgical repair to be performed as soon as possible. Immediately refer the patient to the local emergency department or on call ophthalmologist. This patient will need to be admitted to the hospital and put on bedrest with no food or drink until the surgical repair can be made.
Optic Disc Edema: vision loss with or without pain
The next scenario may be less common, but appropriate management is crucial: A patient presents with optic disc edema. What signs help differentiate an urgent specialty referral from an immediate emergency room referral? Again, a few hypothetical cases can help highlight the differentiating characteristics.
A patient presents with complaints of unilateral vision loss and denies any eye, head, or neck pain associated with the change in vision. The patient also denies scalp tenderness and jaw claudication, dysphagia, weight loss, and fever. There is a definitive ipsilateral afferent pupillary defect and an altitudinal visual field defect. Upon dilated exam the patient is found to have a swollen optic disc, with the classic blurred disc margins and blood vessel obscuration caused by nerve fiber layer edema. There may even be hemorrhages at or near the disc. The fellow disc is not edematous, but is noted to be small and crowded. Assuming this patient is older than 50 years of age, the likely etiology is nonarteritic ischemic optic neuropathy. What should be done for this patient?
Treatment plan: If field loss was determined with confrontation fields, the extent of loss should be mapped with formal visual field testing to confirm altitudinal loss respecting the horizontal midline, or sometimes a central field defect. Because there is little to no suspicion of arteritic optic neuropathy, this patient can be monitored in office monthly, as the edema is expected to resolve over the course of approximately eight weeks and visual acuity can improve for up to six months. The patient should be educated that there is risk to the contralateral eye, asked to return immediately if any new symptoms occur in either eye, and referred to their primary care physician or internist to rule our cardiovascular risk factors, including hypertension, diabetes, or sleep apnea.
In another case, a patient of similar age presents with complaints of unilateral vision loss and does note concurrent headache and scalp tenderness. Again, there is a definitive afferent pupillary defect. This patient has a palpable, tender temporal artery. Upon dilated exam the patient is found to have a swollen optic disc and flame hemorrhages at or near the disc. The fellow disc is unremarkable. Worryingly, this patient’s age and symptoms correlate with arteritic ischemic optic neuropathy, aka giant cell arteritis (GCA). What should be done for this patient?
Treatment plan: Patients with suspected GCA must be evaluated and treated immediately to reduce the risk of vision loss in the fellow eye (though some patients do present with bilateral involvement). This patient needs an immediate ESR, CRP, and platelet count at minimum. The optometrist may be able to order this directly, or in consultation with the patient’s PCP or internist. Alternately, a local ophthalmologist or rheumatologist with which the optometrist has an established relationship may be able to assist in the coordination of care. If not, it is appropriate to send the patient to the emergency department with the recommendation for an ESR, CRP, and immediate consultation with rheumatology to consider a temporal artery biopsy.
Consider a third patient who presents with any of the following: no visual complaint, blurred vision or transient vision loss, headache, or nausea. The patient has no afferent pupillary defect, and may or may not have visual field defects. Dilated fundus examination reveals bilateral disc edema, dilated and tortuous retinal vessels, or retinal hemorrhages at or near the disc. While other entities can cause bilateral disc edema, papilledema caused by increased intracranial pressure must immediately be ruled out.
Treatment plan: An immediate referral to the emergency department is warranted. This patient needs an emergency MRI or CT of the head to evaluate for an intracranial mass. If no space occupying lesion is noted, a lumbar puncture with CSF analysis and opening pressure measurement is appropriate to rule out idiopathic intracranial hypertension.
When is a headache an emergency?
Headaches are a common patient complaint that can present in many shapes and forms, some of which can indeed indicate an ocular or medical emergency. The urgency of the headache can often be determined by its associated characteristics. For example, the head pain may be accompanied by transient vision loss. Other instances may be accompanied by decreased vision, diplopia, neurologic compromise, nausea, or vomiting. Here are a couple hypothetical cases to help differentiate what can be managed in office, and what requires an urgent or emergent referral.
A patient presents with a complaint of vision loss that lasts anywhere between 10 and 60 minutes, and describes the loss as blurry or blacked out peripheral vision that is temporary, and can happen in one or both eyes at the same time. The patient reports several past episodes of similar vision loss, sometimes with or without a subsequent headache. The headache is typically one-sided, described as throbbing, and can occur on either side of the head depending on the given episode. Vision always returns to normal after the event. This type of transient vision loss is fairly common and is easily recognized as a migraine with aura. Remember, “transient” is defined as vision that returns to normal within 24 hours, as opposed to vision loss that persists greater than 24 hours.
Treatment plan: Patients with this type of classic migraine can be managed without urgent referral, and largely revolve around ruling out an ocular or retinal etiology for the visual disturbance, and reassurance if it is the patient’s first migraine experience. It is important to discuss possible precipitating factors or triggers to help the patient identify and avoid these agents. Triggers may include birth control or other hormonal medications, alcohol or certain foods, fatigue, emotional stress, or bright lights. The patient should also be routinely referred to their primary care physician for long-term management, which may include pharmacologic prophylactic or abortive therapy.
Another patient presents with a recurring headache that always causes pain in the same place on one side of the head. Initially, it sounds as if this patient may be having an atypical migraine: the pain presents in the same place each time, but the other symptoms appear to align with a migraine diagnosis. However the patient goes on to state that they are not prone to headaches and any type of head pain is unusual for them. Examination then reveals some type of neurologic symptom, for example, a cranial nerve palsy.
Treatment plan: A one-sided headache with any associated neurologic deficit warrants immediate referral for emergent neuroimaging to rule out intracranial tumor or other structural malformation. Furthermore, a headache that precedes visual symptoms may indicate a mass lesion with cerebral edema and warrants similar referral as well. Etiologies that are more commonly associated with a new headache in a headache-free patient, or headache that is “worse than usual”, include GCA and papilledema as discussed above. It is important to investigate the relevant symptoms and signs that may indicate referral for either of these conditions as well.
Knowing when to refer
It can be difficult to identify whether a patient needs urgent or emergent referral. These were just a few examples to help differentiate urgent and emergent presentations, and additional cases requiring referral can be reviewed here. It is crucial to be able to identify an ocular emergency to act quickly and appropriately. When in doubt, don’t hesitate to reach out to a specialist to discuss the patient’s case.