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In many optometric circles “red eye” has become a
generic term applied to any of a wide variety of ocular emergencies. Symptoms
can range from mild dryness to severe pain and lead to diagnosis from simple
allergies to irreparable loss of ocular function. As varied as these eye
complaints can be, the same holds true for how each patient chooses to attend
to their particular situation. Some may beat your door down over a change in
prescription, while others are content to wait despite devastating
consequences. It is the responsibility of the technician to be vigilant,
especially for those who may not adequately convey their needs. Communication
breakdowns can occur at any level for a variety of reasons. It is important
therefore, to maintain an investigative mindset. The patient will rarely
understand the complete scope of what is wrong with them. Technicians must
endeavor to educate and convey this information in a manner that will promote
compliance. Evaluating and prioritizing patient emergencies according to the
level of urgency is known as “triage.”
The three levels of triage can be
described as follows:
The Emergent or Immediate Case: Needs to be seen within the
hour.
The Urgent Case: Needs to be seen the same day.
The Priority Case: Needs to be seen within days.
THE EMERGENT CASE
The true emergencies are thankfully the rarest, including those
situations where permanent vision loss is immanent danger. Among this category
are:
- Chemical burns
- Retinal artery or vein occlusion
- Penetrating injuries
- Sudden vision loss
Sudden monocular vision loss without pain is most commonly diagnosed as an occluded blood vessel or a
massive retinal detachment.
In a central retinal artery occlusion treatment must be
initiated within 15 minutes or permanent vision loss will occur. If left
untreated for longer than one hour blindness usually results. For this reason,
perhaps more than any other, sudden vision loss should be treated as the
greatest of emergencies. While the diagnosis could alternatively be a vitreous
hemorrhage or retinal vein thrombosis, this symptom must always be treated as
if it were a worst case scenario. One person’s vision saved, after all, is well
worth the nine others who rushed in to less climactic ends.
Retinal detachments represent an immediate threat to the eye
sight as well. They can be sudden and massive as a result of trauma to the head
or slower and more insidious in their progression. When the retina pulls away
from the inside surface of the eye the patient may report symptoms such as
flashes of light, sudden increase in floaters or a curtain/veil over the
vision. These symptoms, especially if reported together should be treated with
greatest urgency.
Chemicals, especially ones with high or low ph, can cause
sudden and devastating injury to the eye. In this situation the longer the
substance is in contact with the eye the worse the resultant damage. The best
treatment that can occur here is one initiated by the patients themselves.
Irrigating the eye for 20 minutes immediately following exposure will go a long
way toward halting the progression of the burn. Since length of exposure time
will greatly affect the extent of the tissue damage it is of critical
importance to irrigate quickly and thoroughly. Any patient reporting exposure
to chemicals should then be instructed to bring the container along with the
material safety data sheet if they are at work. As with the other true
emergencies, these patients are not to be kept waiting. Treatment must be
initiated immediately upon their arrival at the clinic.
Ocular trauma must also be considered at the highest level.
While not all injuries produce permanent effects, most produce significant pain
and rupture of the globe cannot be dismissed over the phone. The most common
eye injury occurs as a result of foreign bodies. Everyone at some point manages
to get something in their eye. Most of the time tearing and blinking reflexes
manage to remove the particle before it causes any damage. It is when this
system fails that emergency measures must be taken. Whether it is dust in the
eye or any other environmental insult, triage of ocular trauma is relatively
simple. The patient can usually relate to the technician a specific event
contributing to the current symptoms and must instructed to come in as soon as
possible.
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| Pterygium |
THE URGENT CASE
The urgent cases should be seen the same day or no later than the next. The
actual red eyes fall into this category along with:
- Swollen lids
- Double vision
- Drooping lids
- Halos
- Photophobia
Any monocular patient with vision complaints should be considered an urgent
case as well. Every effort must be made to maintain the sight in this patients’
good eye.
Red eyes are most commonly diagnosed as viral or bacterial
conjunctivitis. Symptoms include: tearing, discharge, itching, burning,
photophobia,halos and blurred vision. If the patient wears contact lenses, red
eyes and blurred vision can result from sleeping in or over wearing lenses.
Such a patient complaining of terrible pain may also have a corneal tear.
Dehydration can cause the lens to adhere to the corneal epithelium and tear it
away upon removal. This individual may present with the inability to open the
affected eye. Seeing halos around lights is frequently associated with the
previously mentioned conditions. Mucous deposits forming on the surface of the
cornea will split up light rays in much the same manner as a rainbow after a
storm. Cataracts or cysts in the lens can cause this symptom as well but it is
perhaps of greatest significance as a warning sign of impending acute angle
closure glaucoma.
Acute angle closure glaucoma can be easily diagnosed. Onset
occurs within an hour and has a fairly unique sequence of symptoms. Attacks are
usually precipitated by some environmental stimulus that resulted in pupil
dilation. Strong emotional states, darkness and certain medications are the
most common triggers. Many allergy medications contain epinephrine- related
ingredients that are contraindicated for glaucoma suspects. This patient may
report a feeling of pressure or discomfort around the eye in mild cases. The
more severe cases might include severe, incapacitating pain, nausea, vomiting
and light perception visual acuity. They will present in the office with
dilated pupils that do not respond to light. If a patient calls the office
reporting the latter symptoms it should be treated as an emergency and treated
as soon as possible. The former should be seen the same day, preferably within
a couple hours. Symptoms like double vision and lid drooping indicate a muscle
weakness. They must be treated with urgency because they occur as a result of
systemic conditions. Disease of the brain, muscle nerves or muscles themselves
can manifest in this manner. The patient presenting with complaints of double
vision or lid drooping could possibly be facing a diagnosis as serious as:
Myasthenia gravis, brain tumor, aneurysm or even stroke. Lid swelling can be
the result of an infection of the sweat or oil glands in the lid margins, an
insect bite or an allergic reaction. In any case, patients may tend to over
react to this condition because of its disfiguring nature. In reality this is
something that needs to be tended the same or next day but it’s hardly the dire
emergency that might be proposed. In many cases the swelling resolves itself
with little to no formal treatment.
THE PRIORITY CASE
The priority cases should be seen within several days of their initial
complaint.
These include:
- Slow onset blurring of vision. This is usually a prescription change. It is
important however to make sure that there are no other accompanying symptoms.
- Seasonal allergy complaints. Some of these patients will call to request a
refill on a previous medication prescription. They will often have a history of
such occurrences and can occasionally be assisted without a visit.
- Red eyes associated with contact lens wear. Always make sure the patient
understands they are not to wear their contacts until they come in for their
visit. The lens could be damaged or fitting improperly. Wearing it could cause
the cornea to be compromised.
- Lost contact or glasses.
- Ocular migraines and headaches.
Ocular migraines are not a true emergency. They often involve symptoms such as
flashes of light and other visual disturbances though, so it is difficult to
distinguish them from retinal detachments. As always, it is safer to err on the
side of caution. Even if the patient states that a headache followed the
episode, it is well advised that they be seen as an emergency. Headaches are
rarely ocular in origin. Most commonly they are associated with surrounding
structures such as the sinuses or the teeth. They can also occur as a result of
stress, tension and diseases such as hypertension and brain tumor. Ocular
headaches are frequently the result of extended sessions of intense visual
concentration. They can occur anywhere in the brain and should be suspected in
individuals who have had a recent increase in visual demands. This type of
headache is usually relieved by rest and is not associated with any other
symptoms. Patients with complaints that fall into the priority category must
often be treated with a certain degree of diplomacy. Prescription changes and
lost glasses may certainly incapacitate someone, especially a high myope. Their
problems are static though, as easily corrected tomorrow or the next day as
they would be today. It is important to accommodate them to the best of the
clinics’ ability but there are any numbers of ocular emergencies that must take
precedence. The same holds true for the contact lens wearer that is
experiencing irritation when wearing their lenses. Unfortunately they cannot
wear lenses pending an appointment. The situation is controlled though, as long
as the patient complies with instructions.
ON THE PHONE
The screen and triage of patient complaints over the phone can be a daunting
task, to say the least. In a matter of a minute or two a patient must be
interviewed, their symptoms reviewed and the correct level of urgency gauged.
Consider for a moment the idea that 20 patients might call with the same
problem, yet no two of them describe their symptoms in the same words. The true
nature of such difficulty becomes apparent. How then can it be possible to
accurately screen every person that calls? The answer is clearly that it isn’t.
Even with all of the doctor’s knowledge it would be impossible to diagnose red
eyes over the phone.
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| Hordeolum-sty |
Though the patient may want and even expect this when their time is short,
nothing is sure until they are sitting in the chair. All things being
considered, it is not surprising that most techs are reluctant to turn people
away. This is as it should be. It is in this mindset that most healthcare
professionals tend to focus on individual symptoms rather than the whole
picture. If a patient is having flashes of light, for example, most of the time
the diagnosis is ocular migraine. It is more often than not, though, treated as
if it were a retinal detachment. Why? The office can’t be a 100 percent sure of
the reason without the doctor taking a look inside the eye. No one can be
blamed for being over cautious. We are talking about the possibility of saving
someone’s vision. Many optometric and contact lens practices have an
established protocol for handling triage calls. The first and most important
thing to keep in mind is how the patient perceives their symptoms. Despite the
reality of where each case falls in the levels of urgency, the patient is
experiencing an emergency situation. They would not be calling otherwise. A
little sympathy goes a long way toward inspiring patience in one who may be
faced with wait- ing for that prescription check. Alternatively, a measure of
firmness might be appropriate for bringing in that patient who hasn’t realized
the true severity of their symptoms. The caller suspected of retinal
detachment, for example, should be discouraged from waiting until after an
approaching exam to come in. The best way to accomplish this is to present the
possible consequences. Don’t be scary, just be truthful. Present all the
possibilities and why compliance is important. Such a conversation might go as
follows: “We realize that you have a busy schedule right now but we need to
strongly recommend that you come in as soon as possible. Your symptoms may be
nothing more than an ocular migraine but they could also be something much more
serious called a retinal detachment. This condition requires immediate
intervention to prevent permanent vision loss. Since it is impossible to tell
for sure the difference between these two conditions over the phone, we urge
you to come in now to be evaluated.” If the patient still resists complying
with requests to come in immediately it is always wise to call the doctor to
the phone. Sometimes a patient will heed advice more readily when it comes from
the doctor.
During the phone interview with the patient the technician should establish a
detailed picture of the situation. As each question is answered it will assist
in steering the tech toward the appropriate conclusion. Always keep in mind
that not everyone will even volunteer they have a problem. They just call
wanting an appointment, preferring it be sooner than later. Anyone scheduling a
routine exam that is impatient to get in should be screened for possible
emergency situations. It is as simple as asking if there is a reason why they
need to be seen quickly. So what are the questions that need to be asked?
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| Pinguecula |
The best place to start is by asking an open ended question such as: What
symptoms are you having today? Most patients will happily volunteer enough
information to form a basic conclusion. If they began the exchange with a
specific complaint ask if they’re having any other symptoms. The primary
complaint may not always be the one with the red flag attached. Furthermore,
even if they deny the presence of other symptoms it is important to continue
on. What the patient thinks qualifies as a symptom may not match the
technicians’ list. Following are listed some of the more important questions to
be asked. Remember, in answering the phone it is important not to sound like
any type of diagnosis or treatment is suggested. The goal is to assess the
seriousness and whether they need to be seen now, today, or this week.
- What is the chief complaint or
problem?
- When did the problem start or how did it happen?
- Is the problem in just one eye or both? Then ask some more specific questions
to best assess action.
- Are there any flashes of light, floaters or what might appear as a curtain or
shade over the vision?
- Was it a sudden or gradual onset?
- Has there been vision loss or change?
- Is it constant or intermittent in manifestation? If intermittent, how often?
- Rate the severity of discomfort on a scale of 0 to 10.
- Does the problem seem stable or is it getting better/worse?
- Have you attempted self treatment? If yes, please describe.
- Is the discomfort severe enough to describe it as pain?
- Is there any redness?
- Is there light sensitivity?
- Do you have any discharge, debris or matting of the lashes?
CONCLUSION
It is not necessary or appropriate for the technician to be able to diagnose
the patient at first contact though it may seem like that is what is being
demanded. Remember there are two simple rules that will help facilitate the
triage process.
- Red Flags. Red flags preclude further questioning. If you encounter
complaints of flashes, sudden appearance of lots of floaters, sudden vision
loss, chemical contact or trauma there is no need to proceed with further
questioning. They need to be seen as soon as possible. This patient is top
priority regardless of other symptoms.
- Communication. Always suspect there is something the patient has not
volunteered in the initial exchange. Never assume they have told you
everything.
Remember that it is the technician’s job to facilitate communication. The
patient usually does not know what is important any more than they know how to
fix it. Keeping this always in mind proceed with great patience and care. One
grateful patient whose vision has been saved is well worth the effort.
Photos courtesy, Charlie Goldberg M.D., Univ. of California, San Diego
School of Medicine, medicine.ucsd.edu |