The first thing you do is call. Sometimes it’s a pager, most of the time it’s an answering service, because the goal is to put as many human bodies in between you and the consulting ophthalmologist as possible. Now, wait for a call back. This can range from 2 minutes to never. Here’s a handy chart which will allow you to estimate the call back time based on number of years the ophthalmologist has been in practice.
Resident: Call back under 2 minutes
Attending < 1 year experience: Call back under 5 minutes
Attending 1-5 years’ experience: Call back under 30 minutes
Attending 5-20 years’ experience: Call back within 2 hours probably
Attending >20 years’ experience: Jokes on you. That number you called was a fax machine.
Unfortunately, you don’t know how much experience the on call ophthalmologist has because you’ve never seen their face. Consequently, you are left waiting for an indeterminate amount of time for a fax machine that will never call you back. Eventually, the ophthalmologist does call back. The conversation goes something like this:
“Emergency department, this is Pam.”
“Hi Pam this is ophthalmology, I’m returning a page.”
(4 seconds of confused silence)
“Excuse me?...OH, YES! Consult for Dr. Jones. Hold on, I’ll transfer you.”
Every ophthalmologist is a little different with regard to how much information they want to hear. We all want the patient’s history. Ophthalmologists can appropriately triage 90% of eye problems with history alone. Some ophthalmologists only want history and will cut you off after you say “patient with blurry vision—“
I on the other hand, like hearing the exam. Even if the details of the exam end up not being helpful, hearing a description of the patient’s eye exam gives me a good idea how confident the person is with their assessment. Alarm bells go off in my head when I hear a lot of “I think I saw…” or “there may be a…” If the history sounds suspicious for a serious problem and the person I’m talking to isn’t sure where the eyeballs are located in the head, I’m much more inclined to see the patient.
Also, the only way to get better at an eye exam is with PRACTICE. In general, med students don’t learn a decent eye exam, which means residents and attendings on the front lines are learning and improving their eye exam as they go. If I don’t expect them to perform an eye exam, I’m doing that person and the patient a disservice. In the end, I want healthcare professionals to be able to recognize a sick eyeball when they see one.
With respect to vision, history is often more reliable than the actual exam. Checking vision in an emergency department, ICU, or broom closet when the ED is full, is frequently a crapshoot. The patient may not have their glasses. They are probably exhausted. They may have dry eye and haven’t taken any drops for a while. In an emergency situation, history will usually be higher yield than giving an 80 year old a near card. With any change in visual acuity, here are the things I want to know about:
How quick was the vision change? Immediate or over the course of a few days?
How long ago did it occur?
Did the vision come back or has it stayed the same?
Has it progressively worsened?
Was the vision loss associated with pain?
Sudden, painful vision loss is usually bad news. If you tell me a patient has painful vision loss, I’m putting on my shoes. Finally, try to get a sense for the magnitude of the vision change. What is the quality of the patient’s vision now compared to last week? Have the patient describe what they can and can’t see. Can they see TV captions? Can they see your face? Can they see light? A dramatic decrease in vision from baseline is much more worrisome than hearing "my vision is a little blurry" from a 24 year old looking at their phone.
History for diplopia is easy. Here’s what I want to know:
Is it new?
Is it associated with pain?
Is it BINOCULAR?
Diplopia is the 2nd greatest fear among ophthalmologists, right below an in-flight medical emergency and right above ICU consults. You can ease our anxiety immensely if you start the phone call with “I have a patient with MONOCULAR diplopia.” Monocular diplopia is non-emergent. It’s dry eye. At worst, it’s an intraocular lens subluxation. Cover up one eye. If the diplopia goes away, it’s BINOCULAR. If it’s still there, it’s MONOCULAR. Please please please please please please have this information when you call. I beg of you.
Patients come in with all kinds of vague complaints about eye pain. At any given moment in time, there are roughly 180 million people in the US experiencing “pressure behind their eyes.” I know this, because I have seen every one of them. Keep in mind; it’s all about associated symptoms with eye pain. Eye pain without changes in vision (decreased vision, diplopia) is usually nothing to worry about. Always ask about contact lenses. I think that should be the first question everybody gets asked when they check in to the ED.
Triage nurse: Welcome, do you wear contact lenses?
Triage nurse: Great, what brings you in?
Patient: There’s an elephant sitting on my chest
(Please let your administrators know I’m available for all triage related quality improvement projects)
Often, the patient with eye pain is actually experiencing frontal or temporal headache, so it’s important to think about non-eye related diagnoses like sinusitis and giant cell arteritis. I think those are the only things that cause headache. Not sure, there may be others.
If you have a near card or Snellen chart, please use it. It's incredibly important to document vision in any patient who presents with an eye problem. If the patient can read the 20/20 line, that’s good to know. If the patient reads anywhere from 20/30 to 20/80, I want to know, but it doesn’t really help me figure out what’s going on for the reasons I mentioned earlier. It’s hard to get an accurate vision assessment in the ED or ICU and any number of variables unrelated to the chief complaint (refractive error, fatigue, effort) could be contributing to less than 20/20 vision. The patient could be perfectly fine, or they could have a branch retinal vein occlusion or a retinal detachment.
If the patient can’t read “the big E,” don’t stop there! Have them count fingers. If they can’t count your fingers, don’t stop there! Wave your hand in their face and ask which direction it’s moving. If that doesn’t work, shine a really bright light in their face. If they can’t see that, make sure you're not checking vision on a prosthetic eye.
Very few things cause “no light perception” vision: Open globe injury and giant cell arteritis are the most common. Even a patient with a big fat retinal detachment or central retinal artery occlusion will have some vision. The point is, no light perception is a BIG DEAL. That patient needs to see an ophthalmologist in a timely manner.
In addition to some kind of vision measurement, I like having an intraocular pressure (IOP), so pick the tonopen up off the ground in front of whatever wall you last threw it against and use it on the patient. I’m not impressed by anything between 10 and 30. For ED/ICU consults, I’m looking for extremes (way high or way low) as well as big differences between the two eyes. An eye with iritis or a retinal detachment will often have a LOWER pressure than the fellow eye. An eye with angle closure glaucoma will feel like hardened cement compared to the other eye. The lesson here is to always check both eyes. That goes for every part of the eye exam: Vision, IOP, visual fields, slit lamp exam. Both eyes, every time, except in trauma. Please don’t check eye pressure in ANY eye trauma patient. You do not want to mash on an open globe.
The pupil exam is valuable, particularly in cases of decreased vision. If you don’t know how to recognize an afferent pupillary defect (APD), please learn. It’s like THE THING with the pupil exam. I have yet to hear somebody tell me about an APD when calling a consult. We have a big siren with balloons and streamers and everything ready to go when it happens, but so far, nothing. Checking for an APD is good practice, but I will never ask you about it when you call me. It would be nice to know, but I don’t expect it.
You can really help me out with a decent slit lamp exam. Here are some things you can diagnose easily with a slit lamp that will make your on call ophthalmologist swoon followed immediately by frustration because they now have work to do sometime in the next 4-48 hours:
Corneal ulcer (infection)
Those are the biggies. Another tip: If you look through the slit lamp and you CAN’T SEE THE IRIS, something horrible is happening. Call the ophthalmologist.
For the fundus exam, you can try if you want. I have zero expectations.
This is the exam I would like to hear on the phone:
Pupils (helpful, but I won’t be upset if you don’t do it)
Slit lamp exam (always for any vision or pain complaint)
Fundus (don’t worry about it)
Eye movements (only for diplopia and trauma)
Confrontation visual fields (good practice, but I probably won’t ask you about it)
After you run through the history and physical, tell me what you think is going on. Again, some ophthalmologists won’t let you get this far, particularly if it’s the middle of the night or if the wind on the golf course is making it difficult to hear on the phone. When you’re done presenting the patient, I will decide if there is any possible way I can wait until the next clinic day to see the patient. If not, then I’ll see you soon.