Eye Chief Complaints

Eye chief complaints still get me nervous when I see it come on to the tracking board. Bring out the slit lamp exam and the tonopen.

Common chief complaints in UC range from painful red eyes, acute vision loss, to eye trauma and foreign bodies—because let's face it, ophthalmology works from 8 am-9 am and then are on call. Jk jk…eye am only kidding to my friends in Ophthalmology 
 
HippoEd's UC boot camp has five lessons all about the approach to eye chief complaints. As always, be sure to check out HippoEd’s urgent care Boot Camp: here
 
Lots of you have reached out about your interest in subscribing to the course—I’m happy you are all enjoying these summaries. Just a reminder that these are very brief snippets and there is a ton more information that is part of the course. 

Common question: is it worth it? I absolutely, 100% think it is worth the price. I regret not doing this earlier, especially as a new grad. I learned some really outdated approaches to managing specific conditions in my first year of practice, so now I feel like I’m backtracking. Anyway, I highly recommend it for any new grads or just wanting to learn more. Don’t forget, you can use CME stipend money for this too!
 
General approach to eye chief complaints

• Visual acuity is the vital sign of eye—always get this
• Important history to ask—basically ask these for all my pts: 
  • Vision changes
  • Foreign body sensation
  • Photophobia
  • Trauma
  • Foreign body in eye—tetanus UTD?
  • Contact lens wearer
  • flashes/floaters

Common Eye complaints
 
Conjunctivitis

• bacterial, viral, allergic, chemical etiology
• Pearl: Always perform a fluorescein stain of the cornea to avoid missing corneal abrasion, ulcer, herpetic dendrite
• Ointment for children is preferred over drops
• FQ are NOT first line except in contact lens wearers
• Pearl: always close follow up with Ophthalmology—within 24-48 hours

 
Corneal abrasion

• Corneal defect with fluorescein uptake
• Evert upper eyelid to check for retained FB
• Pts will ask for proparacaine eye drops--NEVER prescribe as we want to know if it gets worse!
• Treatment is aimed at preventing infection
• Pearl: always close follow up with Ophthalmology—within 24-48 hours

 
Corneal FB

• Pearl: evert upper eyelid to check for FB
• Remove with saline irrigation, moistened Q-tip, 25-gauge needle
• Don’t need to remove rust rings if pt can follow up with Ophthalmologist
• Tetanus prophylaxis

 
Don't Miss

• Retinal Detachment
  • flashes/floaters of light, dark veil or curtain
  • Test visual fields
  • Emergent Ophthalmology referral

 The painful red eye

​Reminder: these are all getting emergent or urgent referral to Ophthalmology
​

• Glaucoma—acute glaucoma is essentially compartment syndrome of the eye. Mid-dilated pupul, hazy cornea. Measure IOP!
• Orbital disease
  • Orbital cellulitis—painful eye movements. CT of orbits, emergent ophthalmology consult, IV broad spectrum antibiotics

• Scleritis—severe, constant boring pain that worsens at night and morning
• Uveitis—ciliary flush, consensual photophobia
• Conjunctivitis—considered emergency if gonococcal/chlamydia etiology in neonates
• Keratitis
  • Bacterial—Corneal opacity or infiltrate. high risk in contact lens wearers!
  • Viral—Look for dendritic opacity. If dendritic lesions are noted, also look for lesions on top of nose (Hutchinson’s sign) and ear
  • UV—common in welders/snow blindness. Diffuse punctate abrasions with fluorescein 

 

• Infective endophthalmitis—infection of vitreous/aqueous humor, often have history of recent eye surgery/trauma. Emergent Ophthalmology consult
• Topical chemical burns—alkali injuries are more harmful than acidic. Check pH. Add proparacaine. Irrigate with 1-2 L of NS before examination/visual acuity. Continue irrigation until pH remain neutral for 30 min. Don’t forget to update tetanus! If pt condition is worsening—higher level of care for emergency ophthalmology

Liking these UC bootcamp summaries? Let me know how I can best help you below--which chief complains do you struggle with?