Ileana Anika Domondon
Introduction
Junior doctors manage patients with eye symptoms in the Accident & Emergency (A&E) department. However, a systematic review published by Tolley et al. in 2023 revealed there is decreased confidence in managing ophthalmic emergencies among A&E junior doctors in the UK (1). Baylis et al. conducted a survey in 2011 about ophthalmology education delivered across different UK medical schools which found that ophthalmology education varies in terms of standards, methods used and assessments done, with some students receiving no ophthalmology education at all (2). This article aims to serve as a guide for ophthalmic assessment in the A&E.
Ophthalmic History Taking
It is important to take a full ophthalmic history on top of our usual history-taking (e.g. presenting complaint, history of presenting complaint, past medical history, family history, drug history, allergies, and social history)(3).
History of Presenting Complaint
- Laterality (which eye? Both?)
- What is the specific disturbance?
- Associated symptoms (redness, sensitivity to light, visual disturbance or loss, doubling of vision, pain, floaters, flashing lights, itching, discharge, headaches, and vomiting)
- Timing (How quickly did the symptoms come on?)
Patients who present to the A&E with sudden visual loss, a significant decrease in visual acuity, penetrating eye injuries and chemical burns of the eye may have more serious pathology.
RSVP is a useful mnemonic for ophthalmic history red flags.
R: redness (especially when associated with eye pain)
S: sensitivity to light
V: visual loss/disturbance
P: pain (including moderate to severe pain and during eye movement)
Past Ocular History
- Previous or ongoing eye conditions.
- Previous eye surgeries.
- Previous eye trauma.
- Ask if patients wear spectacles or contact lenses.
Family History
- A family history of glaucoma and blindness may be pertinent.
Drug History
- Include eye medications (e.g. drops/ointment).
Social History
- Do not forget to ask if the patient drives and how the patient arrived in the department.
- Include how it has affected the patient’s daily life.
Examination
Visual Acuity
- This is a must and should ALWAYS be done.
- Use the Snellen chart and have the patient start at 6m, one eye at a time. The patient may wear his/her glasses if available. Ask the patient to proceed 1m at a time (until 3m) if he cannot read at 6m. If the patient still cannot read at 3m, then proceed to Counting Fingers (1m) then Hand Movement (at 1m) and lastly Light Perception (3).
- Documentation: distance from chart in metres/ number of lines on the chart.
- Normal: 6/6
Pupils
- Observe the size, shape, response to light, RAPD, and accommodation (3).
Eye Movements
- A systematic manner of doing this is the H-test to isolate the function of the different extraocular muscles.
Visual fields
- Do not forget to check this, especially in patients who complain of visual disturbance (3).
Direct Assessment
- Simple direct inspection of the eye under bright light to look for redness, discharge, signs of inflammation and foreign bodies (3).
Palpation
- Temporal Arteries: check for tenderness in suspected GCA (3).
- Infraorbital nerve: the sensation is important to document in cases of blunt trauma to the eye.
Subtarsal Examination
- In situations wherein you suspect a foreign body in the eye, it is important to evert the upper eyelid because foreign bodies may also lodge underneath the upper eyelid. If not removed, it may cause persistent corneal abrasion (3).
- Procedure: Use a cotton bud to lightly press down the upper eyelid and rotate it upwards while asking the patient to look down.
Slit Lamp Examination
- Allows a detailed examination of the conjunctiva, cornea, and anterior chamber.
- Instil sodium fluorescein drops when suspecting corneal abnormalities. Since fluorescein adheres to the basement membrane and emits a yellow-green light under blue illumination, corneal abrasions will appear yellow-green (4).
- Watching YouTube videos will help familiarize with slit lamp use. Try to perform it when you have ophthalmology cases. If unsure about use, may ask an ED senior for help.
Intraocular Pressure
- Most A&E departments have a handheld tonometer which is straightforward to use.
- Relevant in cases of Acute Angle Closure Glaucoma, Retinal Detachment, Perforation of the globe, and Postoperative Wound Leaks.
- Normal pressure: 10-21 mmHg(5).
Fundoscopy
- Ideally done in a dark room.
- Check for red reflex, retinal vessels, and the optic disc (3).
- May use a mydriatic agent such as tropicamide for better visualization.
Eye pH test
- Important in chemical burns to the eye.
- Check both eyes so you have a baseline ph for the unaffected eye.
- Place the pH strip in the lower fornix for a few seconds and check against the colour scale.
References
1. Tolley A, Mendall J, Parisi V, Hornby S, Nowak V. Confidence of UK emergency department doctors in managing ophthalmic emergencies: a systematic review. Future Healthc J. 2023;10(Suppl 3):60-61. doi:10.7861/fhj.10-3-s60
2. Baylis O, Murray PI, Dayan M. Undergraduate ophthalmology education – A survey of UK medical schools. Med Teach. 2011;33(6):468-471. doi:10.3109/0142159X.2010.540594
3. Wyatt JP, Taylor RG, de Wit K, Hotton E. Oxford Handbook of Emergency Medicine. 5th ed. Oxford University Press; 2020: 550-551.
4.https://eyewiki.org/Slit_Lamp_Examination#:~:text=Instillation%20of%20sodium%20fluorescein%20drops,herpes%20keratitis%20(Figure%206)
5. https://www.ncbi.nlm.nih.gov/books/NBK532237/