When is an ocular medical emergency really an emergency, and when can it wait? Here are some clinical pearls to share with your front of house team.
You’re working at the front desk of your optometry practice. In walks a patient asking for an appointment as soon as possible. The optometrist has been run off their feet and the practice is fully booked for the next couple of days. Regardless, the patient is really worried about their vision and that makes you a bit nervous too. How urgently should they be seen?
If you’re unsure, knock on the door! Your optometrist will be happy to have an eye test interrupted if doing so has the potential to save sight
The following simple steps will help optometrists and front of house teams use their strengths to work together effectively when a patient books an appointment.
- Ask whether the appointment is for a general check up or if there’s something specific they’d like the optometrist to check. This will help determine whether the appointment is urgent or not. It will also help ensure that even if your practice is busy, patients needing urgent attention will not be missed, and sight-saving treatment will not be delayed.
- Allocate time for patients who appear to have more complex needs. This will enable the optometrist to provide appropriate care and reduce the risk of keeping other patients waiting.
- Ask if the patient was referred by another patient, a GP or an ophthalmologist. This will inform the optometrist of the potential need to coordinate care with other allied health care professionals. It will also help your practice know who your referrers are. As an extra step, ensure the referrer receives a thank you.
- Listen carefully, listen to your instincts, and be prepared to ask questions. Questions such as, “when did your vision start to deteriorate?”, or “when did you first notice the symptoms?” can save sight.
If the patient experienced a sudden or very recent change to their vision, it is appropriate to squeeze them in on the day and as quickly as possible. If it’s been a slow change, over a few weeks or more, an immediate consultation is unlikely to change the outcome and the patient should be asked to wait until the first available appointment.
- If you’re unsure, knock on the door! Your optometrist will be happy to have an eye test interrupted if doing so has the potential to save sight.
SOME SYMPTOMS TO TAKE SERIOUSLY
Take particular note if the patient is in considerable pain, they have a very red eye, or they tell you they are extremely sensitive to light, and the symptoms started quite quickly. These symptoms could indicate microbial keratitis – an extremely serious, sight threatening eye infection, acute glaucoma, or uveitis – a severe inflammatory eye condition. These conditions require urgent attention. Squeeze the patient in urgently.
While pain always indicates the need for urgent attention, many sight threatening conditions can be pain free because we don’t have pain receptors in the back of the eye. For example, if a patient complains of very recent changes in their vision, such as unusual, dark floaters and/or flashes of light without pain, they may be experiencing a retinal detachment. This will require an urgent check up and retinal reattachment surgery by an ophthalmologist. Squeeze the patient in urgently.
If a patient complains of a recent and significant drop in vision, or a darkening or loss of vision, they require immediate attention. These symptoms can be caused by a range of conditions that need to be ruled out, including a blocked artery or vein in the eye, or a transient ischaemic attack. The latter could signify an interruption of blood supply to the eye or brain, and may be an early warning sign of an impending stroke.
If your patient has had a very recent eye injury, or presents with sudden double vision, a same day appointment is important to improve outcomes.
TAKE A TEAM APPROACH
All optometrists have their own preferences when it comes to making appointments and determining the level of urgency for particular cases. Optometrists and front of house staff should discuss and agree appropriate action to take.
THE CASE OF STEVE
Steve, a 21 year old second year theology student, started to develop headaches about six months ago. He saw his GP, who said his blood pressure was fine and did not refer him on for any further testing. Steve self-referred to our practice to check whether the headaches had anything to do with his eyes. He told the front of house team his headaches were pretty bad, and he was booked into an appointment on the same day.
Steve was determined to be mildly longsighted, however his vision was a shaky 6/6 in each eye. Everything checked out in the front of his eyes, and even his intraocular pressures were fine. When I checked the back of Steve’s eyes, I noted both optic nerves were severely inflamed. This is known as severe bilateral papilloedema.
Bilateral papilloedema can be caused by benign intracranial hypertension, a severe infection such as meningitis or encephalitis, a brain tumour, or a mass in the brain which places pressure on the optic nerves, amongst other causes.
Benign intracranial hypertension causes swollen optic nerves, however it is not associated with a brain tumour or an infection. This condition is more common in 20–50 year old overweight females, and although it is serious and requires referral, the other causes of swollen optic nerves require more urgent attention.
I explained to Steve that he didn’t conform with the typical patient profile for benign intracranial hypertension. However, I said I was very concerned about a potential brain mass or serious infection.
My front of house team and I called several neuroophthalmologists to obtain an urgent appointment, but as luck would have it, almost every one of them was overseas at the time, attending a neurology conference.
Eventually, after an hour, we managed to make an appointment for Steve to be seen by a neuroophthalmologist at Concord Eye Hospital that afternoon. There it was determined that a large, life threatening brain tumour placing pressure on Steve’s cerebrospinal fluid was causing his severe headaches, the low pseudohyperopic shift in his script, and the severe swollen optic nerves.
On the following day, Steve dropped into the practice to thank us for seeing him urgently, for diagnosing the problem, and taking the extra steps to arrange urgent treatment. Steve had been told that the tumour had been detected just in time, and surgery was scheduled for the next day. The tumour was successfully removed and many years on, Steve has had no further problems.
Optometrists don’t work in isolation. A high functioning care team begins with optometry’s front of house and extends to ophthalmology and the hospital system. The more we do to ensure we work collaboratively, the better the outcomes for our patients’ vision and, indeed, their lives.
Patient name changed for anonymity.
Margaret Lam practises full scope optometry, and has a passionate interest in contact lenses, retail aspects of optometry, and successful patient communication and management. She has extensive experience in specialty contact lens fitting in corneal ectasia, keratoconus and orthokeratology, and is a past recipient of the Neville Fulthorpe Award for Clinical Excellence.
Ms Lam is the National President of the Cornea and Contact Lens Society of Australia and teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer. She works as the Head of Optometry Services for George and Matilda Eyecare. Margaret writes ‘mipatient’ on alternate months with Jessica Chi.