7.4 Ocular emergencies & triage

Ocular Emergencies and Triage

Technicians are frequently the first point of contact for patients who call or walk in with acute eye problems. Rapid, accurate triage, sorting patients by urgency, protects vision, and in a few conditions minutes matter. The technician's job is to recognize red-flag symptoms, initiate the correct first action, and escalate to the physician immediately.

Phone and walk-in screening

Much triage happens by phone before the patient even arrives. A useful screening framework asks four questions: Is there vision loss, and was it sudden? Is there pain, and how severe? Was there trauma or a chemical exposure? Are there associated symptoms such as flashes, floaters, a curtain, halos, nausea, or discharge? Any "yes" to sudden vision loss, chemical splash, significant trauma, or severe pain moves the patient to the front of the line or to an emergency department. For a chemical exposure, the correct phone advice is to begin irrigating at home immediately and come in, not to drive over first, because every minute of contact worsens the burn. Documenting the caller's answers and the advice given is part of safe triage.

The true "do it now" emergencies

• Chemical burns are the single condition where treatment precedes history-taking and examination. For any acid or alkali splash, begin immediate copious irrigation of the eye with saline or clean water for at least 15-30 minutes and continue until the ocular surface pH is neutral. Alkali burns (lye, ammonia, cement/lime) penetrate deeper and are more damaging than acids. Do not delay irrigation to check acuity or gather details; irrigate first and ask questions while irrigating.
• Central retinal artery occlusion (CRAO) presents as sudden, painless, profound vision loss in one eye. Retinal tissue tolerates ischemia only briefly, so CRAO is a stroke-equivalent emergency requiring immediate physician involvement and often emergency evaluation.
• Acute angle-closure glaucoma presents with severe eye pain, headache, nausea and vomiting, a red eye, a mid-dilated non-reactive pupil, blurred vision, and halos around lights. IOP is very high, and prompt pressure-lowering is needed to save vision.

Urgent but slightly less time-critical

• Retinal detachment presents with new floaters, flashes of light (photopsia), and a curtain or shadow spreading across the visual field. A macula-on detachment must be seen the same day, before the macula detaches and vision is permanently lost.
• Penetrating or ruptured (open) globe follows trauma with sharp objects or high-velocity particles. Signs include a peaked or teardrop pupil, prolapsed uveal tissue, a shallow chamber, and low IOP. Protect the eye with a rigid shield and apply no pressure; do not instill drops, measure IOP, or remove a protruding foreign body. Keep the patient NPO in case surgery is needed and avoid anything that increases eye pressure.

Other conditions that need prompt attention

Several additional presentations warrant same-day evaluation even though they are rarely blinding within minutes. Hyphema (blood in the anterior chamber) after trauma raises the risk of rebleeding and IOP spikes and needs shielding and rest. Orbital cellulitis presents with a red, swollen, painful eye, proptosis, restricted or painful eye movements, and often fever, and it is a serious infection that can spread; it must be distinguished from milder preseptal cellulitis. A large corneal abrasion or foreign body causes intense pain, tearing, and photophobia and, while not sight-threatening if treated, is uncomfortable enough to feel like an emergency to the patient. Sudden-onset diplopia with pain, a new severe headache, or vision loss with neurologic symptoms can signal problems beyond the eye and should be escalated at once.

The technician's role

Irrigation is reserved for chemical burns; never irrigate or press on a suspected ruptured globe. Take a focused history (what, when, how), measure visual acuity when it is safe to do so (never before irrigating a chemical burn), and document findings. Recognize that "sudden painless loss of vision" (CRAO, retinal detachment, vitreous hemorrhage) and "painful red eye with vision loss" (angle closure, chemical burn, ruptured globe) are the two symptom clusters that trigger immediate escalation. When in doubt, treat the presentation as urgent and involve the physician; it is always safer to over-triage an eye complaint than to miss a sight-threatening condition. The technician should also stay calm, reassure the patient, and avoid actions such as instilling anesthetic for comfort in a possible open globe, which could introduce infection or delay surgical repair.

Triage and urgency table

Mastering this prioritization, especially the reflex to irrigate a chemical burn before anything else and to shield rather than pressure an open globe, is a core patient-care competency tested on the COT exam and practiced every day in clinic.