What supportive care can an Emergency Medical Technician (EMT)/medic provide for a patient with acute bilateral eye symptoms, including pressure behind the eyes, blurred vision, and double vision?

EMT/Paramedic Management of Acute Bilateral Eye Symptoms

For a patient presenting with bilateral eye pressure, blurred vision, and double vision, EMTs/paramedics should immediately transport to the nearest emergency department—preferably one with ophthalmology capabilities—while providing supportive care en route, as this presentation may represent vision-threatening emergencies including intermittent angle-closure glaucoma (which carries an 18% risk of permanent blindness if untreated) or retinal vascular ischemia (a stroke equivalent). 1, 2, 3

Critical Recognition and Immediate Actions

High-Priority Red Flags to Identify

• Mid-dilated, poorly reactive, or oval-shaped pupils suggest acute angle-closure crisis requiring emergent intervention 1, 2
• Severe photophobia with corneal opacity indicates potential angle-closure glaucoma 1
• Nausea and vomiting accompanying eye symptoms may signal acute angle-closure crisis 2
• Halos around lights combined with pressure sensation suggests intermittent angle-closure glaucoma 1, 2

Transport Decision Algorithm

Immediate transport to ED is mandatory for: 1, 3

• Any vision changes with bilateral eye pressure
• Mid-dilated or poorly reactive pupils
• Severe photophobia
• Symptoms suggesting angle-closure (halos, pressure, blurred vision)
• Any concern for retinal vascular ischemia (stroke equivalent)

Preferentially transport to a stroke center if retinal vascular ischemia is suspected, as these patients require the same urgent stroke workup as cerebral TIA/stroke patients 3

Supportive Care Measures En Route

Positioning and Comfort

• Position patient upright at 30-45 degrees if angle-closure is suspected, as this may help lower intraocular pressure 2
• Avoid having patient bend forward or strain, which can worsen angle-closure 4
• Dim ambient lighting to reduce photophobia and potentially decrease pupillary dilation in angle-closure 1

Vital Signs and Monitoring

• Monitor blood pressure closely, as hypertension is a major risk factor for both angle-closure and retinal vascular events 3, 1
• Assess for signs of stroke including facial droop, arm weakness, speech difficulties, as retinal ischemia is a stroke equivalent 3
• Document exact time of symptom onset, critical for stroke protocols 3

Patient Assessment Details to Communicate

Obtain and relay to receiving facility: 1, 3

• Exact onset time and progression of symptoms
• Presence of halos around lights
• Any head trauma history
• Diabetes, hypertension, or cardiovascular disease history
• Age over 50 and Asian/Inuit ethnicity (high-risk for angle-closure) 1, 2
• Recent viral illness or COVID-19 (can cause bilateral iris inflammation) 5, 6

Critical "Do Not" List

• Do not delay transport for extended scene time—these are time-sensitive emergencies 3, 1
• Do not administer medications that could dilate pupils (anticholinergics, antihistamines) if angle-closure suspected 2
• Do not allow patient to drive themselves even if symptoms are intermittent 1
• Do not dismiss symptoms as "just eye strain" if bilateral with pressure sensation 1

Communication with Receiving Facility

Pre-arrival notification should include: 3, 1

• "Possible acute angle-closure glaucoma" or "possible ocular stroke" depending on presentation
• Bilateral nature of symptoms
• Pupil findings if abnormal
• Time of onset
• Associated neurologic symptoms

For suspected retinal vascular ischemia, specifically state "ocular TIA" or "ocular stroke" to trigger appropriate stroke team activation 3

Special Considerations

Giant Cell Arteritis Screening

Ask patients over 50 about: 3, 7

• Scalp tenderness
• Jaw pain with chewing (jaw claudication)
• Temporal region tenderness
• Recent onset headaches

These symptoms suggest giant cell arteritis, which can cause permanent bilateral vision loss and requires immediate corticosteroid treatment 3

Stroke Risk Context

• Retinal vascular events carry maximum stroke risk within the first 7 days, making immediate evaluation critical 7
• Up to 24% of patients with retinal vascular events have concurrent silent brain infarctions 7
• The American Heart Association classifies retinal arterial ischemia as a stroke equivalent requiring identical urgent management 3

Common Pitfalls to Avoid

• Assuming bilateral symptoms are "less serious"—bilateral presentation actually increases concern for systemic causes including angle-closure glaucoma 1, 2
• Delaying transport because patient "can still see somewhat"—partial vision preservation does not exclude emergencies 1, 4
• Missing the narrow window for intervention—angle-closure has a 50% risk of acute crisis within 5 years if intermittent attacks go untreated 1
• Failing to recognize retinal ischemia as stroke equivalent—these patients need stroke center evaluation, not just ophthalmology 3