Sheryll Kamat

For foundation doctors stepping into the fast-paced environment of the emergency department (ED), ophthalmology can feel like uncharted territory. Training often provides limited hands-on exposure to eye care, and the combination of diverse presentations and specialised tools can make these cases seem intimidating. However, with a systematic approach and a focus on key skills, managing ophthalmic cases in the ED becomes more approachable. This guide offers practical strategies to help foundation doctors build confidence and provide effective care for patients with eye-related complaints.

Recognise Patterns and Red Flags

Effective management of ophthalmic emergencies begins with pattern recognition and identifying red flags, rather than memorising an exhaustive list of diagnoses. Common presentations in the ED include:

• Trauma: Corneal abrasions, foreign bodies, and lid lacerations are frequent. Even without a slit lamp, fluorescein staining under a bright light can reveal corneal damage. In facial trauma, assess extraocular muscle function and visual acuity to rule out extraocular muscle entrapment, optic nerve injuries, and/or a blowout fracture.
• Sudden Visual Loss: Conditions such as retinal detachment, central retinal artery occlusion (CRAO), and vitreous haemorrhage require immediate attention. Patients may describe symptoms like flashes, floaters, or a curtain-like shadow. Listen carefully to their descriptions, as they often differ from textbook terminology.
• Red Eye: Not all red eyes are due to conjunctivitis. Acute angle-closure glaucoma, anterior uveitis, and endophthalmitis can present with redness, pain, and vision changes, requiring prompt ophthalmology assessment. Pay particular attention if the patient has a recent history of cataract surgery, as this raises suspicion for endophthalmitis, a sight-threatening emergency.

A systematic approach that prioritises identifying red flags ensures timely interventions for vision-threatening conditions.

Build Confidence with Ophthalmic Tools and Examination Techniques

Familiarity with basic ophthalmic equipment and techniques is essential for managing eye cases in the ED. These skills can significantly improve both diagnostic accuracy and confidence:

• Slit Lamp Training: Use Professional Development Plan (PDP) days or shadowing opportunities to practise slit lamp examinations. Focus on identifying normal anatomy and common abnormalities, such as corneal ulcers or anterior chamber inflammation.
• Visual Acuity as a Starting Point: Begin every eye assessment with visual acuity, even if the patient does not report vision problems. This simple test often reveals critical conditions such as CRAO or retinal detachment.
• Pupil Assessment and Fundoscopy: Checking for a relative afferent pupillary defect (RAPD) is essential for identifying optic nerve or retinal pathology. Mastering fundoscopy is invaluable, as it can reveal signs such as optic disc swelling or haemorrhages. It is also frequently required in non-ophthalmic presentations, such as hypertension or hypertensive crises, which are common ED presentations. When possible, dilating the pupil allows for a clearer view of the retina, but always ensure to rule out angle-closure glaucoma first.

Consider the Broader Picture: Eye Issues and Patient Impact

• Falls and Independence: Vision loss significantly increases the risk of falls, particularly in older patients. Inquire about recent falls or mobility challenges.
• Driving Safety: Advise patients with impaired vision to notify the DVLA and avoid driving until reviewed by an ophthalmologist.
• Follow-Up Care: Conditions like glaucoma or diabetic retinopathy require ongoing management. If the patient hasn’t been seen by an ophthalmology team recently, inquire about any barriers to care, such as difficulties accessing services. If they are not known to an ophthalmology service, ensure a referral is made or flagged to the patient’s GP to ensure continuity of care.

Prescribe Thoughtfully and Address Pain Adequately

When prescribing medications, always consider how they may impact the eye. Certain drugs can exacerbate or trigger eye conditions, so it’s important to be mindful when treating patients.

• Medication Risks: Avoid corticosteroids in undiagnosed red eyes, as they can worsen conditions like corneal infections or herpes simplex keratitis. Be cautious with drugs that elevate intraocular pressure, such as anticholinergics or steroids, in patients with glaucoma.
• Pain Management: Eye pain can be severe and distressing. Use topical anaesthetics for immediate relief during examination but avoid prolonged use. Escalate care for unrelenting pain, as it may signal serious pathology like acute glaucoma or corneal ulceration.

Stay Informed: Know Your Local Pathways and Guidelines

Awareness of local ophthalmology services and protocols is key to streamlining care:

• Referral Pathways: Familiarise yourself with the operating hours and referral processes for your hospital’s ophthalmology services or eye casualty. This ensures patients receive timely specialist input.
• Triage Systems: Many hospitals have nurse-led triage or urgent referral systems for eye conditions. Utilise these to reduce delays in care.
• First-Line Protocols: Adhere to local guidelines for managing common conditions such as acute red eye, sudden vision loss, or trauma while awaiting ophthalmology review.

Conclusion: Confidence Through Consistency

Although ophthalmic emergencies may initially feel overwhelming, a structured approach and commitment to skill development can help you manage these cases effectively. By focusing on pattern recognition, building proficiency with essential tools, and considering the broader context of each patient’s condition, you can navigate ophthalmology in the ED with growing confidence. Over time, these cases will become an opportunity to safeguard patients’ vision and well-being while enhancing your own clinical expertise.