Recommended Work-Up for New or Worsening Ocular Symptoms
Any patient presenting with new-onset decreased visual acuity, visual field loss, eye pain, redness, photophobia, floaters, or diplopia requires immediate ophthalmologic evaluation with dilated fundus examination and scleral depression to rule out sight-threatening conditions, particularly retinal tears, retinal detachment, acute angle-closure glaucoma, and arteritic anterior ischemic optic neuropathy. 1, 2
Immediate Triage Based on Symptoms
Red Flag Symptoms Requiring Same-Day/Urgent Ophthalmology Referral
Visual acuity worse than 20/40 mandates urgent specialist evaluation within 24 hours, as this threshold indicates potentially serious pathology requiring immediate intervention. 1, 3
Floaters with flashes (photopsias) or peripheral visual field loss indicate possible retinal tear or detachment and require emergency ophthalmologic assessment the same day, as 8-22% of patients with acute posterior vitreous detachment have retinal tears at initial examination. 1, 4, 5
Severe eye pain with redness, blurred vision, and constitutional symptoms (nausea, vomiting, headache) suggests acute angle-closure glaucoma requiring urgent IOP measurement and immediate ophthalmology referral to prevent permanent vision loss. 2
Unilateral vision loss with headache, scalp tenderness, jaw claudication, or temporal artery tenderness in patients over age 50 requires immediate erythrocyte sedimentation rate, C-reactive protein, and complete blood count, with same-day ophthalmology consultation to rule out giant cell arteritis, which can cause permanent bilateral blindness, stroke, or aortic dissection without immediate corticosteroid therapy. 1, 6, 7
Diplopia with proptosis, ophthalmoplegia, pain with eye movements, or eyelid swelling requires urgent evaluation within 24 hours for orbital cellulitis, cavernous sinus thrombosis, or intracranial aneurysm. 3, 8, 6
Essential Initial Ophthalmologic Examination Components
Core Examination Elements
Visual acuity measurement must be documented immediately as baseline, even if patient discomfort compromises testing, to track progression and guide urgency of intervention. 1, 4, 5
Pupil examination including assessment for relative afferent pupillary defect (Marcus Gunn pupil) identifies optic nerve or severe retinal pathology requiring urgent intervention. 8, 6
Intraocular pressure measurement is essential to diagnose acute angle-closure glaucoma (IOP typically >40 mmHg) or rule out elevated pressure from other causes. 1, 8, 2
Slit-lamp biomicroscopy evaluates anterior segment for signs of uveitis, keratitis, corneal damage, anterior chamber reaction, vitreous hemorrhage, and vitreous pigment (Shafer's sign), which has a positive likelihood ratio of 10 for retinal tear. 1, 5
Dilated fundus examination with scleral depression or fundus contact lens is mandatory for all patients with floaters, flashes, or visual field loss to identify retinal tears, detachment, vitreous hemorrhage, or posterior vitreous detachment. 1, 4
Extraocular motility assessment identifies cranial nerve palsies, orbital pathology, or cavernous sinus involvement. 8, 6
Systemic Work-Up Based on Ocular Findings
For Retinal Artery Occlusion (Sudden Painless Vision Loss)
Immediate referral to stroke center or emergency department is required for symptomatic central or branch retinal artery occlusion, as these represent ocular strokes with high risk of subsequent cerebral infarction or myocardial infarction. 1
Emergency laboratory testing includes erythrocyte sedimentation rate, C-reactive protein, and complete blood count with platelets for patients over 50 to rule out giant cell arteritis. 1
Urgent carotid imaging (carotid duplex ultrasound or CT angiography), echocardiography, and evaluation for embolic sources should be performed within 24-48 hours, as carotid endarterectomy improves outcomes for symptomatic stenosis >70%. 1
Antiplatelet therapy and statin therapy apply to the vast majority of affected patients, while carotid surgery applies to less than 30%. 1
For Acute Posterior Vitreous Detachment with Floaters/Flashes
Follow-up examination within 6 weeks is mandatory even if initial examination is normal, as patients have a 2-5% chance of developing retinal breaks during this period, with 80% having pigmented cells, hemorrhage, or new symptoms at the time breaks are detected. 1, 4, 5
Patients with vitreous pigment, hemorrhage, or visible vitreoretinal traction require re-examination within 2 weeks due to higher risk of retinal tear development. 1
B-scan ultrasonography is indicated when media opacity prevents adequate fundus visualization. 1
Optical coherence tomography should be performed if vitreomacular traction is suspected on clinical examination. 1
For Diabetic Patients
Annual comprehensive dilated eye examination is required for type 2 diabetes starting at diagnosis and for type 1 diabetes starting 5 years after onset. 1
Assessment of hemoglobin A1c, blood pressure, serum lipids, and renal status should accompany ophthalmologic evaluation, as systemic control directly impacts diabetic retinopathy progression. 1
Optical coherence tomography is the most sensitive method for detecting and assessing diabetic macular edema in high-resource settings. 1
Fluorescein angiography may be useful to evaluate retinal non-perfusion, neovascularization, or macular capillary non-perfusion when diagnosis is uncertain. 1
For Suspected Infectious Keratitis
Corneal cultures and smears should be obtained before initiating treatment for infiltrates >1mm, central location, or severe presentation, particularly in contact lens wearers. 1
Detailed contact lens history including wearing schedule, overnight wear, solution type, hygiene protocol, and water exposure is essential, as these are major risk factors. 1
Assessment for immunocompromise, diabetes, dry eye, previous herpetic keratitis, and recent ocular surgery identifies patients at higher risk for severe or atypical infections. 1
Common Pitfalls to Avoid
Do not start corticosteroid treatment before ophthalmologic examination in patients with eye redness and pain, as steroids can worsen infectious conditions (herpetic keratitis) or mask accurate diagnosis and severity grading. 1
Do not assume uncomplicated posterior vitreous detachment is benign without follow-up, as 3.4% develop retinal tears within 6 weeks even with initially normal examination. 1, 5
Do not delay giant cell arteritis workup in patients over 50 with vision loss and systemic symptoms, as the fellow eye can become involved within days without immediate high-dose corticosteroids. 1, 6
Do not remove protruding foreign bodies from the eye, as this may worsen globe rupture; instead, shield the eye and arrange urgent ophthalmology evaluation. 2
Do not rely solely on wide-field photography for peripheral retinal examination, as it does not replace careful ophthalmoscopy with scleral depression for detecting retinal tears. 1