How comfortable are you with ophthalmologic exams? If you are an emergency physician who would like to brush up on essential diagnostic procedures within your practice, Jason R. Knight, MD, regional system medical director at Memorial Hermann TeamHealth in Houston, Texas, is your man. In his rapid-fire session, he focused on typical eye complaints, assessing visual acuity, use of equipment, exam techniques, medications, treatments, and when to call in the experts.
Although Dr. Knight offered easy-to-use techniques, he emphasized that the stakes can be high. Misdiagnosis may not be life threatening, but it could lead to permanent vision loss. Additionally, physicians are being sued for missing subtle strokes that come in as ophthalmologic complications.
He recommends that ED physicians start by asking the patient eight questions:
- Does you have pain?
- Any recent eye surgery or trauma?
- Systemic symptoms?
- Foreign body sensation?
- Contact lens use?
- Chemical exposure?
- History of systemic autoimmune disease?
- Previous episodes (such as acute angle-closure glaucoma or herpes)?
Next, check the patient’s visual acuity using an eye chart. If they can’t see the chart, ask them to count your fingers or identify the motion of your hand. At the very least, can they perceive light? Note physical changes such as redness or discharge. Use a panoptic or ophthalmoscope to conduct a retinal exam. Dr. Knight prefers the panoptic because of the larger view it provides of the fundus. “It’s the difference between a 70-inch TV screen versus a 20-inch TV,” he said. A 2011 study showed that emergency physicians using the panoptic were more likely to make a correct diagnosis compared to the ophthalmoscope.
“The slit lamp can be kind of intimidating to physicians,” Dr. Knight said, describing it as a binocular or microscope with a lot of adjustment knobs. “You need to understand less than half of the capabilities of most slit lamps to perform a good eye exam,” he said. He suggested adjusting the settings to 1X magnification, white light, maximum height, and medium width. “Use your finger to hold the lid open or closed for a better view,” he added.
In 2015, EDs are seeing a dramatic increase in the use of the ocular ultrasound. Dr. Knight said that it’s especially helpful for identifying a retinal detachment, open globe, foreign objects, abnormalities, increased intracranial pressure, and hemorrhages. “If you can turn on a machine, you can use this,” he said.
He also noted that physicians are seeing an increase in drug resistant eye infections, including MRSA and other Staphylococcus—something that used to be rare in ophthalmology. If a patient comes to the ED with a history of 10 or more eye procedures, he suggests prescribing strong antibiotics. However, a patient with no history will not need such strong antibiotics.
According to Dr. Knight, the good news is that many of the ophthalmology cases in the ED are seen repeatedly. Getting a good handle on these will make diagnosing eye complaints easier.
Teresa McCallion is a freelance medical writer based in Washington State.