Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States

Scope of practice of oculofacial plastic and reconstructive surgeons: a public perception survey

PURPOSE

The purpose of this study is to determine the public's perception of the scope of practice for oculofacial plastic and reconstructive surgeons (OFPRS).

METHODS

A 49-question survey was distributed by QualtricsⓇ to a panel similar to the US demographic composition. Responses collected underwent bivariate statistical analysis.

RESULT

A total of 530 responses were obtained, with most respondents being white, female, over the age of 35, from the Midwest, and with at least a college education or above. Most respondents did not think ophthalmologists or optometrists were surgeons, and only 158 people (29.8%) knew the primary specialty of OFPRS was ophthalmology. Board certification was preferred by 98.87% of respondents, and 95.28% preferred ASOPRS-trained OFPRS.

CONCLUSIONS

Our study highlights the gap in knowledge about OFPRS as a field, the qualifications and training required, and the scope of practice. Notably, even for OFPRS-specific procedures, PRS remained the leading subspecialist chosen for interventions such as orbital decompression (58.5% vs. 71.5%), orbital reconstruction (57.9% vs. 74.2%), enucleation/evisceration (48.1% vs. 53.4%), optic nerve-related surgery (39.8% vs. 43.4%), orbital cancer resection (42.8% vs. 46.8%), and tear duct surgery (41.9% vs. 52.5%). Additionally, most respondents did not feel that facial fillers, laser skin resurfacing, eyelid cancer removal, or cataract surgery were within the OFPRS scope of practice.

Confidence of Emergency Department doctors in managing ophthalmic emergencies: a systematic review

BACKGROUND

Eye emergencies constitute a significant portion of attendances to general Emergency Departments (EDs) in the UK, therefore it is important to assess the confidence of doctors who work in this setting in managing these potentially sight- and life-threatening presentations. This systematic review aims to assess the confidence of UK doctors working in general EDs in managing ophthalmic emergencies.

METHODS

MEDLINE (Ovid), EMBASE (Ovid), ProQuest Central and Web of Science databases and grey literature were searched from inception to 1 October 2022 for publications that (1) featured doctors working in UK general EDs, (2) assessed doctors' confidence in managing ophthalmic emergencies, (3) contained original data, (4) were full-text, and (5) written in English. Methodological quality was assessed using the AXIS tool.

RESULTS

462 articles were screened, and 7 papers included for data extraction, which collectively assessed the confidence of 956 doctors working in EDs in managing ophthalmic emergencies. There was a widespread lack of confidence amongst foundation doctors, which has worsened over time. Most doctors lacked confidence in performing funduscopy and using the slit-lamp, and considered formal ophthalmology training received in EDs to be inadequate.

CONCLUSIONS

Evidence suggests a lack of confidence amongst foundation doctors in managing ophthalmic emergencies. High-quality evidence investigating the confidence amongst more experienced Emergency Medicine (EM) physicians was lacking. It is important to assess why foundation doctors feel so ill-prepared to manage eye emergencies and develop further ophthalmic training for doctors working in EDs. Further investigation exploring the confidence of EM trainees and consultants is required.

Evaluating patient flow through an emergency ophthalmology consult service in a tertiary care academic centre in Quebec

OBJECTIVE

This study aims to characterize the epidemiology, common reasons, and diagnostic accuracy of referrals made by emergency departments (EDs) and optometrists to an emergency ophthalmology consultation service as well as to identify opportunities for improvement.

DESIGN

Retrospective chart review.

PARTICIPANTS

A total of 1249 referrals made to the emergency ophthalmology consultation service at a tertiary care centre between July 2018 and June 2019.

METHODS

Patient charts were examined, and clinical variables were extracted. Statistical significance (p < 0.05) was determined via t tests and χ2 tests for continuous and categorical variables, respectively. Diagnostic accuracy of providers and time delay between referral and ophthalmologic encounter also were assessed.

RESULTS

Both EDs and optometrists most often referred cases with vitreoretinal (36.48% and 37.19%, respectively) and corneal pathology (21.42% and 20.25%, respectively). Optometrists (n = 240; 52.48%) were significantly more accurate in their diagnoses than EDs (n = 940; 32.45%; p < 0.00001). Specifically, optometrists were significantly more accurate when diagnosing anterior-chamber (n = 29; 58.62%; p = 0.039) and vitreoretinal (n = 89; 60.67%; p < 0.00001) pathology than EDs (anterior chamber, n = 77, 36.36%; vitreoretinal, n = 344, 18.90%). Across all ED referrals (n = 940), 58 (6.17%) had a prolonged delay. Across all optometrist-to-ED referrals (n = 150), 6 (4.00%) had a prolonged delay. Accounting for all cases, the total incidence of prolonged delay was 5.87%.

CONCLUSIONS

Our results demonstrate the need for improved communication between optometrists and ophthalmologists to reduce the wait-time burden on EDs. Patients may benefit from direct referral by optometrists to ophthalmologists. Education of allied health professionals on ophthalmic disease also may improve diagnostic accuracy.

A study on knowledge, attitude, and practices toward ophthalmic emergencies among fresh medical graduates in India

PURPOSE

The purpose of this study was to evaluate and estimate the knowledge, attitude, and practices of Indian fresh medical graduates with respect to ophthalmic emergencies.

MATERIALS AND METHODS

This cross-sectional study was conducted on 1300 participants who had completed compulsory rotatory residential internship with the help of a questionnaire distributed through social platforms. The Chi-square and Pearson's coefficient relation tests were used. Statistical analysis was done using IBM SPSS. P <0.05 was taken as the level of statistical significance.

RESULTS

Good knowledge proportionately corresponded to a good attitude with statistical significance (P = 0.000). Participants with good practice also had a good attitude with significance (P = 0.001). Good knowledge participants who managed ophthalmic emergencies were statistically significant than that of participants with poor knowledge and managed ophthalmic emergencies, 15.72%. (χ2 = 16.653, P = 0.000). Attitude toward confidence in the management of ophthalmic emergencies and their willingness in undergoing training was significant (χ2 = 43.8, P = 0.000).

CONCLUSION

Educating and training fresh medical graduates can help in the management and mitigation of ophthalmic emergencies to reduce ocular morbidity and prevent blindness to a greater degree.

Public and Physicians Perception of Oculoplastic Surgery Subspecialty in Saudi Arabia

Objective

Oculoplastic surgery is a highly specialized subspecialty that studies pathologies of the orbit, lacrimal system, and eyelids. Although it is an independent ophthalmological subspecialty, many procedures fall within the shared scope and anatomical area of oculoplastic surgery, otorhinolaryngology, and plastic and reconstructive surgery, which tend to confuse physicians and patients seeking medical advice. In this study, our goal is to evaluate the perception of oculoplastic surgery among the public and physicians.

Methodology

A cross-sectional study in which data were collected from an online questionnaire formulated by the authors. The questionnaire included 18 questions divided into two categories: demographics and targeted questions that serve the objective of the study. Each answer option to targeted questions was encoded with either one or zero points, and each participant's response was scored accordingly, with the maximum score being 22 points, reflecting the highest perception rate according to the questionnaire.

Results

Data were collected from 1029 questionnaire responses, with 202 of the respondents belonging to physicians. The highest number of responses was from females which consisted 82% of our sample. Perception scores were higher among physicians with a mean of 12.3 ± 2.9 points compared to a mean score of 11.2 ± 2.9 among the public. Age played a statistically significant factor in both physicians and the public as younger participants' scores were higher.

Conclusion

Insufficient knowledge of oculoplastic surgery subspecialty was observed among the public and physicians. Moreover, core aspects of oculoplastic field such as lacrimal system pathology and orbit pathology were less recognized by participants of our study, which highlights the importance of raising awareness of oculoplastic surgery and the diversity of the field, to enhance referral patterns among physicians and improve medical advice seeking among the public resulting in better health care.

Profile of eye-related emergency department visits in Ontario - a Canadian perspective

BACKGROUND

Understanding the epidemiology of ophthalmic presentations to emergency departments can help guide resource allocation, medical education programs, and optimize the patient experience. The purpose of this investigation was to summarize and assess the urgency of ophthalmic presentations in emergency departments (EDs) in Ontario, Canada over a 5-year period.

METHODS

This was a multicentered retrospective review of all patient presentations to EDs in Ontario between January 1st, 2012, to December 31st, 2017. Presentations were included if patients had an ophthalmic related ICD-10 code as their primary problem prompting ED presentation.

RESULTS

A total of 774,057 patients patient presentations were included across the pediatric (149,679 patients) and adult (624,378 patients) cohorts. The mean (SD) age at presentation was 47.4 (17.9) years, and 6.54 (5.20) in the adult and pediatric cohorts respectively. Of the total presentations, 256,776 (33.1%) were due to a trauma related presentation. Problems pertaining to Cornea and External disease were the most common reason for presentation (51.0% of cases). Of all presentations, 34.1% were classified as either 'emergent' or 'likely emergent'; the remaining presentations were either 'non-emergent' (39.5%) or the urgency 'could not be determined' (26.4%). The three most frequent presentations were due to conjunctivitis (121,175 cases or 15.7%), ocular foreign bodies (104,322 cases or 13.5%), and corneal / conjunctival abrasions (94,554 cases of 12.2%).

CONCLUSIONS

This investigation summarizes all ophthalmic presentations to EDs in Ontario, Canada over a 5-year period. The results of this investigation can help guide ophthalmic related knowledge translation. Additionally, these results highlight that in Canadian EDs, a significant proportion of ophthalmic presentations are nonurgent; systems level efforts to improve access for eye-related complaints to healthcare professionals outside of the ED can help facilitate improved resource allocation. As we emerge from the COVID-19 pandemic, optimising the structure of patient care access is crucial to help alleviate the pressure from overburdened EDs while effectively meeting patient healthcare needs.

Intravenous Thrombolysis for Central Retinal Artery Occlusion: A Look at the Literature for the Emergency Medicine Physician

Central retinal artery occlusion (CRAO) is a subtype of ischemic stroke and true ocular emergency presenting with acute, painless, monocular vision loss. Typical findings include poor visual acuity (VA), impaired color vision, relative afferent pupillary defect, and on fundoscopic evaluation, retinal edema, cherry red spot, and occasionally visualization of retinal artery emboli. While there are no proven treatments for CRAO, options include orbital massage, hyperbaric oxygen therapy, and intra-arterial or intravenous thrombolysis (IVT). This study reviews the current literature on the efficacy of IVT for patients affected by acute, symptomatic CRAO and provides an up-to-date, evidence-based background for emergency physicians (EPs) who evaluate and manage these patients.

Current diagnosis and treatment practice of central retinal artery occlusion: results from a survey among German stroke units

Background

Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency whose optimal management is still under debate and due to the absence of definite guidelines, practice is expected to vary. We aimed to characterize early evaluation as well as acute treatment and diagnostic approaches in German hospitals with a stroke unit (SU).

Methods

In 07/2021, all 335 certified German SUs were invited to participate in an anonymous online survey endorsed by the German Stroke Society on emergency department care organization, diagnostic procedures, and treatment of patients with unilateral vision loss (UVL) subsequently diagnosed with CRAO.

Results

One hundred and sixty-three (48.6%) of the 335 eligible centers responded. Most (117/135; 86.7%) stated that UVL patients were treated as an emergency, in 62/138 (44.9%) hospitals according to specific guidelines. First-line evaluation was performed by neurologists in 85/136 (62.5%) hospitals, by ophthalmologists in 43/136 (31.6%) hospitals. Seventy of 135 (51.9%) respondents indicated a lack of on-site ophthalmological expertise. Seventy-four of 129 (57.4%) respondents performed thrombolysis in CRAO and 92/97 (94.8%) stated that patients with CRAO–if admitted to neurology–were treated on a SU.

Conclusions

Our findings reflect notable heterogeneity in early intrahospital care of CRAO in German SUs but demonstrate a preference for work-up and management as acute stroke by the involved neurologists. Streamlining interdisciplinary emergency evaluation is essential for ongoing and future prospective trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-022-00193-w.

The burden of flashes and floaters in traditional general emergency services and utilization of ophthalmology on-call consultation: a cross-sectional study

Purpose

To characterize the healthcare utilization and clinical characteristics of patients presenting with flashes and/or floaters (F/F) in general emergency service (GES) settings.

Methods

All adults presenting to GESs (emergency departments (EDs) and urgent care centers (UCCs)) with symptoms of F/F in Hamilton, Ontario between Jan. 1 – Dec. 31, 2018 were reviewed. Primary outcome was the proportion of patients presenting to GESs with F/F for which ophthalmology emergency services (OESs) were consulted. Secondary outcomes included features predictive of OES consultation by logistic regression and cost of GES utilization.

Results

Of 6590 primary eye-related visits to GESs, 10.4% (687) involved symptoms of F/F. Mean age of patients with F/F was 57 ± 15 years, and 61% were female. Consultation rate to OESs for F/F presentations was 89% (608/687). Logistic regression identified symptoms ≤ 2 weeks (OR 8.0; 95% CI 2.3–28), ≥ 45 years age (OR 2.4; 95% CI 1.4–4.3), UCC setting (OR 2.7; 95% CI 1.6–4.6), headache (OR 0.22; 95% CI 0.12–0.41), and neurologic symptoms (OR 0.1; 95% CI 0.19–0.49) as variables predictive of OES consultation. Mean time from triage to discharge in GESs for F/F patients was 2.43 ± 2.36 h. Mean cost per visit was $139.11 ± $113.93 Canadian dollars. Patients for which OES were consulted waited a total of 1345 h in GESs and accounted for $81,879.70 in costs.

Conclusion

Patients presenting with F/F in GESs consume considerable resources in healthcare expenditure and time spent in GESs and most receive OES consultation. Identifying these patients at triage may allow for increased efficiency for the healthcare system and patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02613-6.

A Systematic Analysis of the Impact of an Ambulatory Ophthalmology Urgent Care Clinic

Importance A same-day ophthalmic urgent care clinic can provide efficient eye care, a rich educational environment, and can improve patient experience.

Objective The aim of this study was to systematically evaluate volume, financial impact, care metrics, and the breadth of pathology of urgent new patient encounters based on their site of initial presentation.

Design, Setting, and Participants A retrospective analysis was performed on consecutive urgent new patient evaluations in our same-day triage clinic at the Henkind Eye Institute at Montefiore Medical Center between February 2019 and January 2020. The cohort of patients who presented directly to this urgent care clinic were referred to as the “TRIAGE” group. Patients who initially presented to an emergency department (ED), and were subsequently referred to our triage clinic, are referred to as the “ED + TRIAGE” group.

Main Outcomes and Measures Visits were evaluated on a variety of metrics, including diagnosis, duration, charge, cost, and revenue. Furthermore, return to the ED or inpatient admission was documented.

Results Of 3,482 visits analyzed, 2,538 (72.9%) were in the “TRIAGE” group. Common presenting diagnoses were ocular surface disease (n = 486, 19.1%), trauma (n = 342, 13.5%; most commonly surface abrasion n = 195, 7.7%), and infectious conjunctivitis (n = 304, 12.0%). Patients in the “TRIAGE” group, on average, were seen 184.6% faster (158.2 vs. 450.2 minutes) than patients in the “ED + TRIAGE” group (p < 0.001). The “ED + TRIAGE” group were furthermore found to generate 442.1% higher charges ($870.20 vs. 4717.70) and were associated with 175.1% higher cost ($908.80 vs. 330.40) per patient. The hospital was found to save money when noncommercially insured patients with ophthalmic complaints presented to the triage clinic instead of the ED. Patients seen in the triage clinic had a low rate of readmission to the ED (n = 42, 1.2%).

Conclusions and Relevance A same-day ophthalmology triage clinic provides efficient care, while providing a rich learning environment for residents. Less wait time with direct access to subspecialist care can help improve quality, outcome, and satisfaction metrics.

Benefits to utilising ultrasound in examining the eye

Ocular ultrasound (US) is not one of ACEMs 'big 5' in terms of US capability that is expected of a trainee or FACEM. Most texts have a small chapter dedicated to ocular US but it is usually at the back or a subsection of a chapter where it is rarely seen or appreciated. However, it is a straightforward scan to perform with many benefits which will be discussed in this article. The eye offers an excellent medium for US beam penetration, making good quality images of the retina easy and quick to acquire. This has the added benefit of being able to share images with an ophthalmologist remotely, improving time to definitive treatment. It can also be used in patients who cannot cooperate with sitting at a slitlamp, for example moribund or trauma patients. The authors propose that ocular US teaching should be incorporated into the ACEM syllabus, being a vital adjunct to a comprehensive eye examination.

Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness

BACKGROUND AND PURPOSE

Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency necessitating adequate and comprehensive diagnosis. Its optimal management and treatment, however, are still under debate. This study aimed at identifying respective areas for improvement.

METHODS

We retrospectively analysed the medical records of patients with CRAO treated in our stroke unit between January 2016 and August 2020.

RESULTS

During the observational period, 101 patients with CRAO were admitted. We observed an increase in the rate of patients primarily admitted to the stroke unit from 52.2% to 97.4%. In addition, the thrombolysis rate - with thrombolysis performed on an individual basis - rose from 0% to 14.1%, coinciding with the implementation of an in-hospital management guideline. Almost 60% of all patients presented outside of the 4.5-h time window for thrombolysis; by far the most common reason not to deliver intravenous thrombolysis in our cohort was a prehospital delay to presentation (58.8%), with 44.4% of patients having consulted a private-practice ophthalmologist first. A total of 25 (32.5%) of 77 patients who underwent magnetic resonance imaging (MRI) had accompanying acute ischaemic stroke lesions on diffusion-weighted MRI of the brain. A possible aetiology of CRAO was identified in 41.4% of patients.

DISCUSSION

Public awareness of sudden unilateral visual loss as a presenting sign for stroke should be raised, increasing the chances for timely recognition in a hospital with ophthalmological expertise and a stroke centre. This is essential for ongoing and future prospective trials on this subject.