Management of patients with eye complaints within Adult ED

Transcription

1 Management of patients with eye complaints within Adult ED Full Title of Guideline: Author (include and role): Division & Speciality: Version: 1 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): 26/07/2023 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this guideline has been created from: Guideline for the management of patients with eye complaints within UH Adult ED 2200hrs-0700hrs Jaimie Coleman jaimie.coleman@nuh.nhs.uk Emergency Medicine Consultant Ricardo De-sousa Peixoto Ricardo.De-sousaPeixoto@nuh.nhs.uk Ophthalmology StR Medicine, Emergency Department ED and Ophthalmology Governance teams Clinicians working within the adult Emergency Department Inclusion criteria: Patients assessed within the Adult ED who present with a complaint that is likely due to an ophthalmological cause. Patient presents between the hours of 2200hrs and 0700hrs seven days per week. Exclusion criteria: Patients within the Paediatric Emergency Department or any other department/ward that is not Adult ED. Patients who do not have an eye complaint, or condition requiring an ophthalmic assessment. /A Standard ophthalmology textbooks/online guidance and discussion amongst UH Opthalmologists This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. 1

2 Assessment of eye problems in UH Adult Emergency Department >10pm Use the triage tool (page 5) for streaming Use the diagnosis-based tool if you are confident of the diagnosis (page 6,7,8) Use the flow charts (pages 10-15) to provide advice for symptom-based presentations Only call the ophthalmology SpR on-call if the charts advise you to. Page 4 advises of the process to transfer patient to C25 if suitable, otherwise patient can remain in ED for review If patient requires eye casualty in the morning they are to call ext at 0900hrs. 2

3 Assessment of eye problems in UH Adult Emergency Department A grab bag will be brought by eye casualty staff to blue team doctors office at 2200hrs and collected at Call C25 if no bag has been brought. The bag contains: All relevant medications All relevant equipment Instruction sheets Patient advice/discharge leaflets Paper to log all overnight ophthalmology attends (please write k number) 3

4 Standard Operating Procedure for transfer of an emergency Ophthalmic patient from ED to C25 between and Why? If a patient in ED between hrs has been assessed as needing an Ophthalmology review. Patients attending ED between hrs should be directed to eye casualty as per current ED triage process if deemed appropriate When? To be transferred to C25 within 30 minutes of patient assessment To be discharged on Medway to C25 How? Decision made by ED clinician, using Eye Cas for ED guideline, that Ophthalmology review is necessary. DW on-call Ophthalmologist and, if the Ophthalmologist is in agreement that the patient needs to be seen, transfer to C25. ame and K number of patient to be given. Inform C25 coordinator that the patient is being transferred to their care, handover clinical information and the name of the Ophthalmologist who is coming. Ambulatory pts with EWS <4 can be sent without any nurse escort C25 will now have responsibility for delivery of care, maintaining the safety of the patient and support for the Ophthalmologist seeing the patient. Patient will be classed as a ward attender (the same as ET and MF pts) Pt will be either: 1. Ward attender > discharged 2. Ward attender > admitted 3. Ward attender > Eye Casualty review in the morning. Documentation on C25 C25 to print out labels. Patients notes recorded on paper with demographics added by Dr (the same as ET and MF) If not admitted completed notes are to be put in Ward Attender tray at reception. Ward reception staff will book pt on Medway as Ward Attender If patient is for review in Eye Casualty the notes will be brought to dept. 4

5 UH ED Quick Reference urse Triage guide for Eye Complaints hrs Is there a penetrating eye (globe) injury or blunt trauma causing proptosis (bulging eyeball) O Complete painless loss of vision in one or both eyes O?Acute Glaucoma Excruciating non traumatic eye pain, often fixed or dilated pupil ES ES ES Eye Casualty Opening Times are 07:00-22:00hrs everyday. All patients attending ED during opening times with purely an eye complaint should be streamed to eye casualty ext Inform ED Consultant, ACP or doctor immediately for assessment Triage Cat 2 Resus or ellow dependent on presentation O Chemical eye injury O ES Start saline irrigation See instruction in pack Ensure Isolated Eye Complaint Triage as Cat 6 To be seen in TA by ACP/Doc Analgesia as required, observations only if indicated Any concerns please discuss with ACP / IC / Consultant 5

6 Trauma Penetrating injury Chemical injury Blunt trauma Corneal abrasion Findings Loss of AC form CT orbit shows globe rupture ph 7 after irrigation corneal abrasion vision deteriorated Lid swelling CT head (for #) Deterioration of VA Geographic area of fluorescein staining Clear cornea (no FBs, no white spots) Actions Contact ophthalmology Preservative Free chloramphenicol, dexafree, celluvisc & cyclopentolate 1% Dilate with cyclopentolate 1% Refer # to maxfax for assessment PF chloramphenicol g cyclopentolate 1% Lid laceration Pad and patient call eye cas at 0900 Hyphaema Hyphaema Presence of blood accumulating in inferior AC Usually result of trauma IOP may be > 21 mmhg If < ½AC maxidex and cyclopentolate 4xd If > ½ AC or IOP > 25 contact ophthalmology Headache/eye pain Acute glaucoma Temporal arteritis Migraine Excruciating eye pain ausea and vomiting Dull cornea with mid dilated pupil IOP > 40 mmhg Visual symptoms Temple pain and tenderness Jaw claudication Weight loss and lethargy Very high ESR and CRP Positive phenomena in both eyes ausea and headache Photophobia IOP < 30 mmhg Contact ophthalmology Manage nausea and pain Prescribe 1mg/Kg oral prednisolone with bone and stomach protection If VA deteriorated - If VA not affected, refer to TAB pathway* Standard ED treatment 6

7 Double vision Contact lens Corneal graft Third nerve palsy Sixth nerve palsy Fourth nerve palsy Monocular Ulcer retained CL Findings Acute onset (<4h) Ptosis, Eye down and out Unreactive pupil Acute onset Horizontal double vision Vasculopath Acute onset Likely head trauma in young, stroke in elderly Vertical double vision which gets better with tilting head Actions CT angio head with contrast If cerebral problems refer to neuro surgery for orthoptic review for orthoptic review for orthoptic review CT head if concerns Double vision with one eye occluded Improves or resolves with pinhole Pain, red eye Contact ophthalmology Fluorescein uptake White spot in cornea Most likely there isn t a CL If CL present remove with foreceps and prescribe Test by instilling 2% fluorescein and checking levofloxacin 4xd with blue light. CL will glow green. In all cases patient call eye cas at 0900 Contact ophthalmology Endophthalmitis If ~1/52 post op or intravitreal injection Loss of VA Severe ocular pain Unwell Contact ophthalmology Post op high IOP Signs as for acute glaucoma Contact ophthalmology Post op Post op bleed Pressure pad Ice Less than 2/7 post op or intravitreal injection give chloramphenicol 4xd Corneal abrasion - Check cornea with fluorescein 7

8 Cellulitis Pre-septal Mostly lid swelling Recent trauma/ insect bite / chalazion-lid lump FROEM PEARL o RAPD White eye Prescribe co-amoxiclav 625mg tds Orbital Proptosis Deterioration of VA RAPD Defective Ishihara Recent history of URTI Red eye CT head, then Start IV augmentin, ET assessment Maxfax assessment Only then, Contact ophthalmology on call Loss of vision CRAO Sudden and complete loss of vision Painless If less than 6h onset contact ophthalmology If over 6h onset Floaters/ Flashing lights Conjunctivitis bacterial Green/yellow purulent discharge Crusty lids Chloramphenicol Viral Clear or white discharge Gritty pain Injected Recent URTI Chloramphenicol Contagion advice Hand hygiene * to refer to Temporal Arteritis service log in to outlook on your profile and type Temporal arteritis on the To: box. This should prompt you a link that sends the to rheumatology (for follow up), to ophthalmology (for Temporal Artery Biopsy) and to Ultrasound (for temporal ultrasound). 8

9 Definitions AC anterior chamber BE both eyes BRVO Brach retinal vein occlusion CL contact lens CRAO central retinal artery occlusion FROEM Full range of eye movements IOP intra ocular pressure PEARL pupils equal and reactive to light PF preservative free PL perception of light RAPD relative afferent pupillary defect TAB temporal artery biopsy URTI upper respiratory tract infection VA visual acuity 9

10 Red Eye Painful? IOP >40 +/or Fixed dilated Pupil? Discharging? Contact lens wearer? Green/yellow discharge Fluoroscein stained spot? Treat as bacterial conjunctivitis. Patient call eye cas at 0900 Treat/discharge as viral or allergic conjunctivitis Patient call eye cas at 0900 Patient call eye cas at 0900? Acute glaucoma? Lens ulcer Refer to ophthalmology SpR Use i-care tonometry to measure IOP Use blue light post fluoroscein 10

11 Painful loss of vision (including headache) Concurrent with red eye? Follow red eye chart (risk of glaucoma) Positive phenomena Flashing lights, zigzag lines, Kaleidoscopic distortion Migraine see UH headache pathway Temporal tenderness +/- Jaw claudication +/- Weight loss +/- Lethargy Unilateral Swollen optic discs Bilateral swollen discs Suspect Temporal arteritis?optic neuritis?temporal arteritis?intracranial hypertension?intracranial pathology Discuss with rheumatology Check ESR etc Start steroid treatment Discuss with neurology Discuss with neurosurgery 11

12 Painless loss of vision Monocular likely ophthalmic Binocular likely neurologic Temporary Amaurosis fugax? Follow TIA guideline Permanent Patient call eye cas at 0900 Positive RAPD ESR >40 and CRP >25 Suspect Temporal arteritis VA < 6/60?CRAO egative RAPD < 6h Discuss with rheumatology Check ESR etc Start steroid treatment Call ophthalmology SpR Limb weakness or Slurred speech Involve Max fac if trauma related Follow Stroke guideline 12

13 Double vision Monocular diplopia (i.e. double vision with good eye occluded) Patient call eye cas at 0900 Dipolopia due to proptosis call ophthalmology SpR All other causes are likely neurological and should be initially investigated and referred onward as such with eye cas review in the morning if required 13

14 Eye chemical/thermal injury triage tool Ocular Chemical injury immediate assessment required Solid/particulate chemical e.g caustic soda/cement start irrigation and Call Ophthalmology SpR Liquid chemical Step 1. Chemical injury (acid/alkali); instill G.Proxymetacaine and then irrigate for 15 minutes Step 2. Check ph; is 7.0 achieved? es Check ph again 15 minutes and 30 minutes. If ph 7.0 at 30 minutes go to step 3. o Repeat step 1 after re-applying G.Proxymetacaine and use cotton bud to check fornices Step 3. prescribe lubricants hourly, Oc.Chloramphenicol QDS, G.Cyclopentolate BD. If unable to get ph to 7 or any concerns Call Ophthalmology SpR Eyelid thermal burns Step 1. Check for ocular injury, examine eye: fluorescein staining? es Oc.Chloramphenicol QDS, G.Cyclopentolate BD. o Step 2. If burn injury to eye lids; apply Oc.Chloramphenicol and Jelonet dressing Obtain advice from Plastics team regarding eyelid and associated burns + 14

15 SHARP IJUR Penetrating injury to the globe (signs e.g: puncture wound, leak observed with fluorescein, loss of vision) Call Ophthalmology SpR Minor injury e.g. corneal abrasion (not a contact lens user) (signs e.g. fluorescein staining of cornea and mechanism of injury mild e.g. scratch). Treat with OC.Chloramphenicol QDS 5/7 Lacerations to eye lids: Any defect (even if full thickness/lid margin involving), clean wound, close with steristrips, Abx as indicated EE TRAUMA TRIAGE TOOL History Check Vision Fluorescein staining Check Intraocular pressure BLUT IJUR Bruising and swelling of eyelids due to trauma Assessment/investigation of possible facial fractures including orbital floor fractures (CT etc). All periocular injury including confirmed orbital floor fractures. IF Protruding tense globe unable to retro-pulse Call Ophthalmology SpR Otherwise and contact MaxFac as appropriate Hyphaema - (signs e.g: blood level visualised in the front chamber of the eye) Check intraocular pressure and look at how much of anterior chamber is filled with blood >1/2 depth and/or pressure over 25mmHg Call Ophthalmology SpR <1/2 depth and pressure not raised call eye cas at 0900 Red eye Traumatic iritis e.g. sore eye, photophobia, pupil may be enlarged Subconjunctival haemorrhage 1. if borders of subconjunctival haemorrhage seen, no impairment in vision and painless discharge with advice 2. If borders not seen and impairment vision Call Ophthalmology SpR 15