Abdul Muhyemin Tarin
Introduction
Tertiary eye casualty departments in the United Kingdom are often inundated with high volumes of patients from broad catchment areas. Patients may self-present during opening hours, arrive after being signposted from local or regional accident and emergency departments, referred by optometrists and general practitioners, or sent from smaller neighbouring ophthalmic departments. This constant inflow can overwhelm the system to breaking point, causing significant delays and leaving patients and staff extremely frustrated.
To address these pressures, it is essential that such departments implement an effective triage system. The Royal College of Ophthalmologists, in its national guidance The Way Forward: Emergency Eye Care(1), emphasises the critical need for triage in high-demand eye units, recommending consultant-led models to improve patient prioritisation, reduce waiting times, and ensure timely management of serious conditions. A structured triage process not only enhances clinical safety but also supports better resource utilisation in increasingly stretched departments.
Evidence from Banerjee et al. further supports this model (2). Their study demonstrated that the introduction of triage, even when led by trained nurse practitioners, significantly improved patient flow and reduced inappropriate use of clinical time. It showed that early stratification of urgency allowed for more efficient allocation of care, especially in walk-in services dealing with a wide spectrum of anterior and posterior segment pathology.
This approach enables the timely categorisation of patients into low, medium and high priority groups, minimises unnecessary delay, and facilitates prompt initiation of appropriate treatment. Patients can be managed swiftly at triage, referred to a scheduled outpatient clinic, or escalated as true emergencies to be seen in eye casualty. These measures help to streamline patient flow, improve throughput, and prevent breaches in waiting times while maintaining high standards of care.
This report outlines a practical triage framework tailored to walk-in, high-volume tertiary eye departments.
Triage Room Set-Up
A triage room must be optimized to support high patient throughput, quick clinical assessment and efficient documentation. The following tables illustrate essential components required.
Physical Set-Up: Key Requirements
| Component | Specification / Role |
| Dedicated Room | Positioned near reception or casualty entrance; not shared with other clinics |
| Desk Space | For triage documentation and storage of equipment |
| Computer | For documentation on electronic patient record and access to outcome software and patient list |
| Printer | For generating clinical letters, prescriptions, leaflets, etc. |
| Sink + PPE area | For infection control compliance |
| Chairs | Office chair + adjustable patient chair + spare chairs for seating relatives/friends |
Staffing Model
| Staff Member | Responsibility |
| Triage Clinician | Consultant or senior registrar; performs focused history, anterior segment exam, triage decision |
| Triage Nurse | Assists with visual acuity, documentation, outcoming and patient flow |
| Receptionist | Assists with booking appointments, printing documents, other queries |
Essential Equipment Checklist
| Equipment | Purpose |
| Slit Lamp | Anterior segment exam |
| Portable Slit Lamp | For use in children or immobile patients |
| iCare Tonometer | Rapid measurement of intraocular pressure |
| Visual Acuity Chart / App | Vision screening |
| Ishihara Plate | Screening for optic nerve function |
| Pen Torch | RAPD check and pupil reflexes |
| Fundal Lens | Quick general view of fundus in undilated pupil |
| Prescription Pad | For issuing medications |
| Gloves, Cotton Buds, Gauze, etc. | Routine clinical use |
Topical Medication
| Item | Purpose |
| Fluroscein Sodium | Detecting corneal epithelial defects |
| Tropicamide 1% + Phenylephrine 2.5% | Dilation for posterior segment exam |
| Oxybupracaine 0.4% / Proxymetacaine 0.5% | Topical anaesthesia |
Triage Workflow
Patients typically present through one of three main pathways. The majority are self-referred walk-ins, representing the first point of contact for their ocular concern. The second group comprises patients referred by general practitioners, optometrists, accident and emergency departments, or other regional hospital units. These individuals usually arrive with a referral document outlining a brief description of their problem. The third cohort consists of patients attending scheduled follow-up appointments after a previous clinical review.
Upon arrival, patients must first register at reception. Their details are entered into the hospital workflow system, and identification labels are printed and attached to any accompanying documentation. The patient is then assigned to the triage queue.
A triage nurse or doctor then calls the patient into the designated triage room, ideally located adjacent to the reception and main waiting area. At this point, patients are briefly reminded of the triage process to set expectations for a focused consultation.
The triage clinician—usually a consultant or senior trainee—begins the assessment by reviewing any available referral documentation. In many cases, this information alone is sufficient to categorise the patient into one of three triage priority levels: low, medium and high complexity cases. Similarly, patients attending follow-up appointments can often be promptly assigned to a designated urgent care clinic or prioritised for emergency review after a quick check of their previous consultation notes on the electronic patient record. If the concern relates to the posterior segment, dilating drops may be prescribed in advance to streamline the patient journey.
In instances where a patient self-presents without documentation, a brief, focused history should be conducted. The aim is to determine whether the issue lies within the anterior or posterior segment and the process should take no longer than one minute. If blurred vision is the presenting complaint, a quick visual acuity screen can be performed using a displayed LogMAR chart or smartphone app. This should act as a rapid screen, not a formal measurement. The anterior segment can then be examined using the slit lamp available in the triage room. Intraocular pressure should be assessed using an iCare tonometer. If a posterior segment issue is suspected, the pupils should be examined for a relative afferent pupillary defect, and dilating drops—such as tropicamide and phenylephrine—can be prescribed for use after formal acuity testing by a nurse.
Based on these findings, the provisional triage outcome is determined. Patients with low-priority anterior segment issues can be managed and discharged directly from triage with verbal instructions and medication as needed. Medium-priority patients should be scheduled into the urgent care pathway and should await a formal visual assessment by a nurse. If long waiting times are anticipated, patients should be informed and given the option of receiving a near-future appointment in the urgent care clinic.
Patients requiring urgent assessment should be escalated to the eye casualty doctor for immediate review. In some cases, initial treatment can be administered and investigations initiated while awaiting formal assessment.
All triage outcomes must be documented in the electronic patient record or paper notes. Any instructions to nursing staff regarding investigations or treatment should also be clearly recorded. The triage nurse is responsible for updating the patient’s triage outcome on the clinical system, whether through discharge or redirection to the appropriate area.
This streamlined process enhances clinical efficiency, prioritises high-risk cases, and reduces unnecessary delays—ensuring that tertiary centres can continue to deliver safe and effective care in a high-demand environment.
Common Presentations
Low Priority Presentations in Eye Triage
| Condition / Presentation | Triage Outcome |
| Dry eye | Given lubricating drops and discharged |
| Blepharitis | Given blepharitis leaflet; advised on lid hygiene and warm compresses; discharged |
| Chalazion | Given chalazion leaflet; advised on warm compresses; discharged |
| Infected chalazion / Hordeolum | Prescribed Maxitrol (or equivalent) drops; discharged |
| Corneal abrasion | Prescribed chloramphenicol drops; discharged |
| Subconjunctival haemorrhage | Reassured; advised BP check ± INR if on anticoagulants; discharged |
| Viral conjunctivitis | Given lubricants; advised on hygiene measures; discharged |
| Allergic conjunctivitis | Prescribed lubricants and/or antihistamine drops (e.g., olopatadine); discharged |
| Pinguecula | Reassured; lubricants and discharged |
| Mild episcleritis | Reassured ± lubricants ± weak steroid (e.g. FML); discharged |
| Superficial ocular surface foreign body | Removed at triage with cotton swab, discharged |
Medium Priority Presentations in Eye Triage
| Condition / Presentation | Triage Outcome |
| Corneal foreign body (not removable in triage) | Booked into urgent care for removal and assessment with fluorescein staining |
| Anterior uveitis | Booked into urgent clinic same day; AC cells recorded and instructions for VA and dilation |
| Mild anterior scleritis | Check if blanches with phenylephrine and record results, check AC activity, VA and instructions for dilation |
| Mild blunt trauma (e.g. football injury) | Booked into urgent care; check VA, IOP, anterior chamber depth; dilate if needed |
| Flashes and floaters (new onset) | Booked for same-day dilated fundus exam |
| Pre-septal cellulitis | Booked into urgent clinic same day to assess optic nerve and exclude orbital cellulitis; alternatively initiate oral antibiotics and book follow up if confident in diagnosis |
| Dacryocystitis | Booked into urgent clinic; alternatively initiate oral antibiotics and book follow up if confident in diagnosis |
| Marginal keratitis | Booked into urgent clinic; alternatively initiate topical mild steroids and discharge if confident |
| Herpetic keratitis | Booked into urgent clinic; alternatively initiate oral and/or topical antivirals according to local protocols and book follow up if confident in diagnosis |
| Allergic keratitis / severe allergic conjunctivitis | Booked into urgent clinic; alternatively antihistamines ± steroid drops if moderate symptoms |
| Embedded ocular surface foreign body | Booked into urgent care clinic for removal |
High Priority Presentations in Eye Triage
| Condition / Presentation | Triage Outcome |
| Sudden unexplained loss of vision | Immediate review in casualty; screen VA, dilation and posterior segment assessment; request mac/disc OCT after nurse assessment |
| Suspected papilloedema | Escalate to eye casualty; check VA, colour vision/pupils/confrontational visual fields, dilate, check BP, mac/disc OCT |
| Optic neuritis | Escalate to casualty; VA, colour vision and RAPD assessed; dilate |
| Acute onset diplopia | Arrange urgent orthoptics appointment if available, escalate to eye casualty |
| Acute onset ptosis (with diplopia or pupil involvement) | Check pupils for ?Horner’s syndrome, refer for urgent orthoptics if necessary, escalate to eye casualty |
| Significant blunt or penetrating ocular trauma | Immediate casualty review, CT scan can be requested urgently |
| Lid laceration (margin- or canalicular-involving) | Immediate casualty review and primary repair |
| Acute angle-closure glaucoma or ocular hypertension with IOP >40 mmHg | Prescribe IOP-lowering drops and IV Diamox in triage, escalate to eye casualty |
| Suspected retinal detachment | VA, dilate; Mac OCT, urgent fundal exam by casualty doctor |
| Intermediate/posterior uveitis | Escalate to casualty; dilate for vitreous and fundus exam |
| Chemical eye injury (acid/alkali) | Immediate pH testing and copious irrigation done by nurses; escalate urgently |
| Suspected CRAO/CRVO or GCA | Immediate review; dilate pupils, arrange urgent bloods (ESR/CRP), OCT |
References
- The Royal College of Ophthalmologists. (2017). The Way Forward: Emergency Eye Care. London: The Royal College of Ophthalmologists.
- Banerjee, S., Beatty, S., Tyagi, A., & Kirkby, G. R. (1998). The role of ophthalmic triage and the nurse practitioner in an eye-dedicated casualty department. Eye, 12, 643–647.