What are the immediate steps for emergency ophthalmology referral in cases of sudden vision loss or severe eye trauma?

Emergency Ophthalmology Referral Protocol for Sudden Vision Loss and Severe Eye Trauma

In cases of sudden vision loss or severe eye trauma, immediate referral to an emergency department or stroke center is required, as these conditions represent true ophthalmic emergencies that can lead to permanent vision loss if not promptly addressed. 1

Immediate Assessment and Triage

Sudden Vision Loss

• Central Retinal Artery Occlusion (CRAO)

  • Consider as a stroke equivalent requiring immediate transfer to nearest emergency department affiliated with a stroke center 1, 2
  • Do not delay for additional ophthalmic testing 1
  • Risk of stroke is highest within first 7 days and remains elevated for 30 days 2
  • Delay in referral decreases chance of good outcome by 8-14% for every 30-minute delay 1

• Giant Cell Arteritis (GCA) Suspicion

  • For patients over 50 years with symptoms like temporal tenderness, jaw claudication, weight loss, proximal myalgia, or fever 2
  • Immediate high-dose systemic corticosteroids should be initiated 1
  • Emergency ophthalmology referral within 24 hours 2

Severe Eye Trauma

• Globe Rupture/Penetrating Injury

  • Immediate referral to emergency department
  • Avoid applying pressure to the eye
  • Shield the eye without touching it
  • NPO status in anticipation of possible surgery

• Chemical Injuries

  • Immediate irrigation with sterile saline or clean water for at least 30 minutes
  • Emergency ophthalmology referral within 24 hours

Referral Timeframes

Emergency (Within 24 Hours)

• Central retinal artery occlusion (CRAO) 2, 1
• Suspected giant cell arteritis 2
• Globe rupture or penetrating injury
• Chemical burns
• Severe eye pain with vision loss
• Severe DROSD (Dupilumab-related ocular surface disorders) 2

Urgent (Within 1 Week)

• Moderate to severe vision loss with ocular inflammation 2
• Eyelid swelling with pain and erythema, proptosis, pain with eye movements 2
• Movement restriction/diplopia, vision changes 2

Standard/Routine

• Mild to moderate DROSD not responding to topical treatment 2
• Follow-up after initial emergency treatment

Critical Actions During Referral Process

1. For CRAO:

   • Transfer immediately to stroke center 1
   • Brain MRI with diffusion-weighted imaging or CT if MRI unavailable 1
   • Vascular imaging (MRA, CTA, or carotid ultrasound) 1
   • Cardiac evaluation including ECG 1
   • Laboratory tests: CBC, chemistry panel, lipid panel, HbA1c 1
   • ESR and CRP for patients over 50 years to rule out GCA 1

2. For Severe Eye Trauma:

   • Protect the eye from further damage
   • Avoid applying pressure or medications to the eye
   • Document visual acuity if possible before referral

3. For Suspected GCA:

   • Immediate high-dose systemic corticosteroids 2
   • ESR and CRP testing 1

Post-Emergency Follow-up

• Regular monitoring for neovascularization which may require panretinal photocoagulation 1
• Assessment for preservation of residual vision 1
• Vision rehabilitation services for significant vision loss 1
• Neurological follow-up within 2 weeks after discharge for CRAO patients 1

Common Pitfalls to Avoid

1. Delayed Referral: Only one-third of ophthalmologists transfer CRAO patients to emergency departments, despite evidence showing time-sensitivity 1

2. Inadequate Initial Assessment: Failing to determine characteristics of vision loss (monocular vs. binocular, transient vs. persistent, painful vs. painless) 1

3. Starting Treatment Before Proper Evaluation: Avoid starting systemic or topical corticosteroids prior to eye exam unless indicated for concurrent non-ophthalmological toxicity 2

4. Overlooking Systemic Conditions: Up to 70% of patients with CRAO have significant systemic cardiovascular conditions requiring urgent evaluation 2, 1

5. Missing GCA: Failure to consider GCA in patients over 50 with temporal headache, jaw claudication, and elevated inflammatory markers can lead to bilateral blindness 2

Remember that ophthalmic emergencies represent immediate threats to the visual system that can lead to permanent vision loss if not promptly addressed and properly managed.