What does an ophthalmologist (eye doctor) need before consulting a patient with photophobia, blurred vision, and floaters in the left eye after a 20-foot fall?

Ophthalmologic Evaluation Requirements After Traumatic Head Injury

For a patient with photophobia, blurred vision, and floaters in the left eye following a 20-foot fall with loss of consciousness, ophthalmology requires a complete ocular trauma assessment including visual acuity, pupillary examination, intraocular pressure measurement, and dilated fundus examination before consultation.

Initial Assessment Required Before Ophthalmology Consultation

Essential Components

1. Visual acuity testing

   • Best-corrected visual acuity in both eyes 1
   • Pinhole testing to assess best potential acuity 1

2. Pupillary examination

   • Size and response to light
   • Presence of relative afferent pupillary defect (RAPD) 1, 2
   • Document any asymmetry

3. Intraocular pressure measurement

   • Preferably with Goldmann applanation tonometry
   • Note: May defer contact tonometry if corneal trauma is suspected 1

4. External examination

   • Eyelid position and function
   • Globe position and integrity
   • Evidence of orbital trauma or fractures 1

5. Slit-lamp biomicroscopy

   • Examine cornea for abrasions, lacerations, or foreign bodies
   • Assess anterior chamber for hyphema or inflammation
   • Evaluate lens for traumatic cataract or dislocation 1

6. Dilated fundus examination

   • Crucial for evaluating vitreous for hemorrhage or detachment
   • Assessment for retinal tears, detachment, or commotio retinae
   • Optic nerve evaluation for traumatic optic neuropathy 2

Additional Testing to Consider

1. Visual field testing by confrontation 1, 2
2. Ocular motility assessment for restrictions suggesting orbital fracture 1
3. B-scan ultrasonography if media opacity prevents adequate fundus examination 2

Documentation Requirements

Document the following findings in your consultation request:

• Mechanism of injury (20-foot fall with loss of consciousness)
• Duration and progression of symptoms (photophobia, blurred vision, floaters)
• Visual acuity measurements in both eyes
• Pupillary responses and presence/absence of RAPD
• Intraocular pressure readings
• Anterior segment findings
• Posterior segment findings (if visible)
• Any associated neurological symptoms

Urgent vs. Emergency Referral

Emergency Referral (Same Day)

Indicated for:

• Decreased visual acuity with signs of retinal detachment
• Vitreous hemorrhage
• Hyphema
• Significant ocular trauma with vision loss 2

Urgent Referral (24-48 hours)

Indicated for:

• Stable visual acuity with floaters but no signs of retinal detachment
• Mild anterior segment inflammation without pressure elevation

Important Considerations

• Do not delay ophthalmology consultation if there are signs of retinal detachment (curtain-like vision loss, numerous floaters with flashes) as this requires immediate intervention 2

• Avoid pupillary dilation if there is concern for increased intracranial pressure or if neurological assessment is ongoing after head trauma

• Cycloplegic agents may be needed for examination but can cause photophobia, blurred vision, and increased intraocular pressure as side effects 3

• Orbital imaging (CT scan) should be obtained prior to ophthalmology consultation if orbital fracture is suspected, as this will guide management decisions 1

• Document any pre-existing ocular conditions that may affect interpretation of current findings

By providing this comprehensive assessment before ophthalmology consultation, you will facilitate more efficient and effective specialty care for this patient with potentially serious ocular trauma following a significant fall.