Eyes

Eyes are a bit like teeth. We have dentists because most doctors don’t like teeth. We have optometrists because most doctors don’t like eyes. But sometimes people with eyes do need a doctor and these patients often come to Emergency first. So now it’s your turn to work out how to look at an eyeball.

The ACI eye emergency manual is a terrific resource. I can’t rate this more highly. It should be your first resource for any eye presentation in Emergency.

This blog will focus simply on the basics of history and examination. If you can examine the patient’s eye thoroughly before speaking with the ophthalmology reg on call you will exclude most dangerous problems even if you’re not sure what’s going on.

History

You want to ask every patient a few general questions:

• Do you wear glasses? Do you wear contacts? Are you wearing these now?

• Did you bring your glasses? (They didn’t.)

• What happened at the time of your eye injury?

  • Any trauma? (punch to the eye, squash ball vs eye etc)

  • Did you sneeze or cough?

  • Any recent woodworking, chain sawing, metalworking? Did you wear protective goggles?

There are several very common conditions that you will see such as corneal foreign body or corneal abrasions. These usually have a trauma history where other conditions causing painful eye or loss of vision do not.

Past Medical

• Any eye conditions and what drops or injections they have

• Autoimmune conditions (Rheumatoid arthritis, Sjogren’s)

• Diabetes

Exam

Focus on a detailed step-by-step exam. Take your time. Many of these steps take some practice. Before you see your eye patient get a registrar or your boss to run you through the slit lamp or tonometer if you have these. You don’t want to be fiddling around with this in front of the patient trying to work out how to turn it on.

Visual Acuity

Missing visual acuity is like calling Cardiology without an ECG. Do the basics well.

Many eye rooms will have a Snellen chart on the wall. Make sure this chart is the appropriate distance away. Due to space, many Emergency departments will have this chart above the patient’s head and then get the patient to look in a mirror for the chart to be the required distance away. Test one eye at a time with glasses on if possible.

If your patient cannot read English, use a tumbling E chart. If you don’t have a Snellen chart, then get one up on your phone on MD calc.

If your patient can’t see any text (this is bad) you can hold up fingers for your patient to count. If they can’t do this then you can wave your hand in front of their face or shine a light in their affected eye – can they see movement? Can they detect any light?

Pinhole

Most patients do not bring their glasses. I cannot tell you why. If this is the case, and they’re short-sighted, use a pinhole on each eye to see if it improves their visual acuity and record this too.

Ophthalmoplegia

Draw a slow H in front of the patient’s eyes. If one of their eyes becomes “stuck” and is unable to follow your finger, then it implies an extraocular muscle issue. Patients will describe double-vision (diplopia).

Pupils

Assess the light response on both pupils. Are the pupils symmetrical and round? An irregularly-shaped pupil occurs in some eye conditions like corneal lacerations and anterior uveitis.

Relative Afferent Pupillary Defect (RAPD)

You can test this immediately alongside the pupillary reflex. It’s easy to do with the swinging light test. In a normal examination, both pupils will constrict when either pupil is exposed to light. In an affected pupil, both eyes will be more dilated when light is shone on the affected side. This implies a relative afferent pupillary defect.

Evert Eyelids

Look under the eyelids for retained foreign bodies or lesions. Check the patient does not have false eyelashes first. Hold the lashes, press on their upper eyelid with a Q-tip and look under the lid.

Slit Lamp Exam

I’ve attached a video from Eyeballs Made Easy to describe the main steps. The difficulty is understanding what buttons and switches and knobs do what. Go through it with your senior before you see a patient. It gets easier with practice and repetition.

Fluorescein

This is usually the most fruitful aspect of an emergency eye exam. There are different strengths of fluorescein, the higher versions being up to 2%. This more concentrated fluorescein is best used to look for globe rupture. If a more dilute form is unavailable then I put in a single drop, ask the patient to blink as much as they can and leave the room for 5-10 minutes. If I stay in the room, I’m too tempted to look too early and there will be too much dye in the eye to see very much of anything.

After the dye is in, look at the eye with the cobalt blue filter (not the green filter. Unless you do ophthalmology, you will never need the green light in your life. It is just there to trick you). You can use the slit lamp or an ophthalmoscope. Look for areas of uptake such as a corneal ulcer or punctate lesions.

Tonometer

The tonometer is used to measure intraocular pressure. If your shop has one, please use it. It’s very helpful and part of the eye exam. This measurement is essential in diagnosing several eye emergencies.

Ophthalmoscope

Using the ophthalmoscope for fundoscopy is one of the dark arts of medicine. If you’ve never done this before then don’t expect to see much. But do continue to try, or you’ll never see anything. My advice is to get the room very dark, use as little light as possible and have the patient look at the corner of the ceiling behind you. This gives you the best chance of getting a good view of the optic disc at least.

If your department has a retinal camera, good for you! This is way better.

Extras

Some Emergency registrars will be able to do an ocular ultrasound. This is actually very easy and will quickly tell you if a patient has a retinal detachment. It’s worth getting someone to have a look with the US in someone with sudden visual loss.

Management

It’s almost never going to be an issue to prescribe chlorsig drops for a patient with a sore eye to prevent secondary infection. Check with your senior if the eye registrar needs to be involved with your patient. Eye patients are often followed-up in clinic – an urgent eye review afterhours is quite uncommon.

Many patients with a sore eye will get topical anaesthetic drops in triage which gives some relief and aids assessment. The current advice is that these should not be given on discharge.