Top 10 Ophthalmology Emergencies on Call

These top 10 diagnosis will cover 80% of all emergency room consults you are called in for. Learn how to manage these well, and you will feel very confident taking ophthalmology call. They are sorted in rough order of prevalence. The steps listed are not all inclusive, but a high-level framework for you to start thinking about these situations.

1. Corneal abrasions / foreign bodies / ulcers

   • Your job:  Take cultures, initiate appropriate treatment, manage pain, and bring the patient back for follow up in 1-3 days depending on severity. (see Corneal Ulcers)

2. Flashes and floaters – retinal detachment rule out

   • Your job: A good depressed exam, ensuring there is no retinal tear / detachment. 90% of these calls will be posterior vitreous detachments, and will require only monitoring. If you are unsure, call in backup. There is one important distinction here: macula on or macula off. If the macula is ON, surgery is generally indicated urgently, as the prognosis is worse if the detachment eventually reaches the macula. If the macula is already OFF, the situation is less emergent, and the standard of care is usually to do surgery within a few days. This is because it is impossible to diagnose and get a patient to the OR within the ~90 minute time frame it takes before there is permanent ischemic damage to the retina. If you find a flap tear without detachment, you will usually call in backup to help laser around the flap tear the same day.

3. Orbital fracture – muscle entrapment rule out

   • Your job: use forceps to perform forced ductions to ensure that the eye can move in all directions. Perform a dilated exam to rule out intraocular trauma if feasible. Very few orbital floor fractures actually result in entrapment (~5%), and it is exceptionally rare in the age group that generally experiences falls (old people) as their bones are brittle, and the orbital floor generally breaks, leaving a fissure.

4. Ruptured globe

   • Your job: Confirm rupture, prep the patient for the operating room. While some retina surgeons may schedule a mac on retinal detachment repair the next day, almost nobody will wait on a ruptured globe. Time is of the essence, as expulsion of ocular contents can occur with coughing, sneezing, bearing down, and infection can wreak havok on an open eye. Your job is to call in your surgical backup and get things prepped for the operating room. A very gentle exam is indicated, and most ophthalmologists will even advocate against checking IOP given the risk of expulsing ocular contents if ruptured globe is suspected.

5. Acute angle closure glaucoma

   • Your job: to break the acute attack. Prescribe the maximum IOP lowering drops: prostaglandin analogue (latanoprost), beta blocker (timolol), alpha agonist (brimonidine), and a topical carbonic anhydrase inhibitor (dorzolamide, if patient unable to take systemic acetazolamide). Pilocarpine can be used to miose the pupil and deepen the angle breaking the attack. Often, multiple rounds of drops separated by 30-60 minutes are required to lower the IOP. Systemic acetazolamide or even IV mannitol can be used to decrease the eye pressure. Some hospitals’ practice patterns have you do the YAG laser iridotomy that same night, others will want you to wait a day for the cornea to clear up.

6. Arterial / venous occlusions

   • Your job: get labs to identify risk factors, especially the risk for GCA with ESR and CRP. Bring patients back for OCT / FA / additional imaging to determine if anti-VEGF injections are necessary. Carotid ultrasound should be done for artery occlusions. Some people get an EKG and ECHO. There are some people who believe O2 or ocular massage will help a CRAO, we usually start patients on O2 and massage since they are essentially risk free. Hyperbarics are higher risk and require that particular team to assess benefits vs. risks.

7. Vitreous hemorrhage

   • Your job: Use the indirect to look for an occult tear. If no view, use B scan ultrasound to look for a detachment. If no tear and patient is a diabetic, 99% of the time you have a diabetic vitreous hemorrhage from proliferative diabetic retinopathy. Have the patient follow up in Retina clinic based on the standard waiting times for operating on vitreous hemorrhage patients. If there is a tear, you would get in touch with your backup to potentially laser / perform retinal surgery.

8. Orbital cellulitis

   • Your job: Use clinical factors to determine if patient has orbital cellulitis. Though it is a clinical diagnosis, patients often get CT / MRI of the orbits anyway. If the patient is diagnosed with orbital cellulitis, admission and IV antibiotics are necessary. If the patient just has preseptal cellulitis, let the ED figure out whether patient should be admitted or get oral antibiotics.

9. Eyelid laceration

   • Your job: rule out a globe. If that’s ruled out, you have to suture up the eyelid. In addition, you have to make sure the nasolacrimal drainage system is not lacerated. This is generally done by irrigating each puncta with a nasolacrimal cannula and making sure it doesn’t flow out anywhere where it shouldn’t. The process of suturing is different if its margin involving or not. Get your backup to help you with your hospital’s practice pattern for closing these lacerations.

10. Papilledema

    • Your job: most times the reason you are being called is because the other guys can’t definitely see the papilledema and want you to confirm. If you do see it first, then your job is to do figure out whether it’s an ocular or non-ocular etiology. Here is a DDx to get you started:
      Systemic causes: idiopathic intracranial hypertension (IIH), optic neuritis or MS, meningitis, subdural/epidural/subarachnoid hemorrhage, cerebral venous sinus thrombosis.
      Ocular causes: NAION, AION, CRVO, diabetic papillopathy, uveitis, optic nerve tumors, pseudo-papilledema.