Which ophthalmological cases should be referred from Urgent Care (UC) to ophthalmology evaluation the same day?

Ophthalmological Cases Requiring Same-Day Referral from Urgent Care to Ophthalmology

Urgent Care providers should immediately refer patients with retinal artery occlusions, posterior uveitis, severe visual impairment, or acute angle-closure glaucoma to ophthalmology for same-day evaluation to prevent permanent vision loss.

Vascular Emergencies

Retinal Artery Occlusions

• Central Retinal Artery Occlusion (CRAO) or Branch Retinal Artery Occlusion (BRAO)
  • Patients presenting with sudden, painless vision loss should be treated as medical emergencies
  • These conditions represent ocular strokes and indicate high risk for cerebral stroke
  • Patients should be referred to both ophthalmology AND the nearest stroke center/emergency department 1
  • Up to 24% of these patients have concurrent cerebrovascular accidents on MRI 1
  • The risk of stroke is highest within the first 7 days and remains elevated for 30 days 1

Transient Monocular Vision Loss (TMVL)

• Even if vision has returned to normal, these patients require urgent referral
• May represent transient retinal ischemia (ocular TIA) and indicates stroke risk 1
• Should be referred to both ophthalmology and a stroke center for evaluation

Inflammatory Conditions

Uveitis

• Posterior or Pan-uveitis: Requires URGENT ophthalmology referral (preferably uveitis specialist) prior to initiating treatment 1
  • Unlike anterior uveitis, posterior uveitis can be asymptomatic but can rapidly progress to visual loss
  • Do not start corticosteroid treatment before ophthalmology evaluation as it may mask diagnosis or worsen conditions due to infection

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis with Eye Involvement

• Daily ophthalmological review is necessary during the acute illness 1
• Apply ocular lubricants every 2 hours through the acute illness
• Requires specialized ocular hygiene by an ophthalmologist or ophthalmically trained nurse

Acute Angle-Closure Glaucoma

• Presents with eye pain, redness, blurred vision, halos around lights, headache, nausea, and vomiting 2, 3
• Represents a true ophthalmological emergency with markedly elevated intraocular pressure
• Can cause permanent vision damage if not treated promptly
• Can sometimes present atypically with painless vision loss, mimicking other conditions 4
• Patients on certain medications (sympathomimetics, anticholinergics, etc.) are at higher risk 5, 6

Severe Visual Impairment

• Any patient with sudden blindness (20/200 or worse) in the affected eye 1
• Marked decrease in visual acuity (worse than 20/40) with symptoms limiting self-care activities 1
• Any acute, unexplained vision loss

Dupilumab-Related Ocular Surface Disorders (DROSD)

• Severe DROSD: Requires ophthalmology assessment within 24 hours or urgent assessment within 1 week 1
• Initiate preservative-free ocular lubricants while awaiting ophthalmology evaluation

Other Urgent Conditions

• Suspected Giant Cell Arteritis: Patients with visual symptoms and elevated inflammatory markers should be seen immediately 1

  • Delaying glucocorticoid therapy when visual loss is present is the strongest risk factor for permanent blindness

• Ocular chemical burns: Immediate irrigation and referral

• Orbital cellulitis: Eyelid swelling with pain, erythema, proptosis, pain with eye movements, movement restriction/diplopia, vision changes 1

• Penetrating eye injuries and ruptured globes

• Retinal detachment symptoms: Sudden onset of floaters, flashes of light, or a curtain/shadow in visual field

Important Cautions

• Do not start topical or systemic corticosteroids before ophthalmology evaluation for eye conditions, as this may mask diagnosis or worsen infectious conditions 1

• For patients with retinal artery occlusions, coordinate care with both ophthalmology and stroke services, as these patients require evaluation for stroke and other cardiovascular risk factors 1

• When in doubt about the urgency of an eye condition, err on the side of caution and refer for same-day evaluation

By following these guidelines, urgent care providers can help ensure that patients with vision-threatening conditions receive appropriate and timely care to preserve vision and prevent permanent visual impairment.