Ophthalmologic procedures in the emergency department

Rapid progression of orbital abscess requiring lateral canthotomy in a pediatric patient

Subperiosteal abscess (SPA) is a rare complication of acute sinusitis in children that may develop rapidly. In this case report, we describe an 11 year-old boy who presented with a large SPA 2 days after being diagnosed with conjunctivitis. The patient required emergent lateral canthotomy and cantholysis (LCC), IV antibiotics, and emergent surgery. It is crucial that emergency physicians be able to identify and treat this vision-threatening complication.

Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis

Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.

Topical pain control for corneal abrasions: A systematic review and meta-analysis

OBJECTIVES

Corneal abrasions are common ophthalmic presentations to emergency departments. Among emergency physicians and ophthalmologists, there are highly variable practice patterns with regard to management of resultant pain and discomfort. The goal of this study was to review and analyze the efficacy and safety of topical pain therapies for corneal abrasions, including topical anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), cycloplegics, steroids, pressure patching, and the use of a bandage contact lens (BCL).

METHODS

The review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The protocol was established a priori and published on PROSPERO (CRD42020201288). MEDLINE, EMBASE, CENTRAL, and Web of Science were searched until December 31, 2020. Primary studies comparing topical pain therapies to another therapy or control were included. Primary outcomes included percentage of corneal abrasions healed at 24, 48, and 72 hours, as well as pain control at 24 and 48 hours. Secondary outcomes included use of oral analgesia and incidence of complications. Risk of bias was assessed using validated tools. Quality of evidence was assessed using the GRADE methodology.

RESULTS

Overall, 33 studies (31 randomized controlled trials [RCTs], two cohort studies) comprising 4,167 patients with corneal abrasions were analyzed. Only the data for topical NSAIDs were of adequate evidence from which to draw conclusions; topical NSAIDs demonstrated significantly reduced pain scores at 24 hours (standardized mean differences [SMD] -0.69, 95% CI = -0.98 to -0.41) and 48 hours (SMD = -0.56, 95% CI = -1.02 to -0.10) as well as 53% (95% CI = 34% to 67%) lower oral analgesia use compared to control. Based on available data, topical anesthetics, cycloplegics, patching, and the use of a BCL did not result in any significant difference in pain scores or use of oral analgesia, while no studies examined topical steroids. No interventions resulted in healing delays or significantly higher rates of complications compared to controls.

CONCLUSIONS

There was strong evidence to support that topical NSAIDs reduce pain associated with corneal abrasions in the first 48 hours and the need for oral analgesia. The existing evidence was insufficient to support or refute the use of topical anesthetics, cycloplegics, steroids, or BCL for pain control in corneal abrasions. Pressure patching was ineffective at pain reduction and may increase the risk of complications. Delays in healing or other complications were not significantly different between any intervention or control for simple, uncomplicated corneal abrasions; however, larger RCTs are required to identify any differences in rare complications.

Utilization of emergency ophthalmology services in Taiwan: a nationwide population study

The aim of this study was to conduct a nationwide survey of the use of emergency ophthalmology services using a sub-dataset of one million beneficiaries sampled from Taiwan’s National Health Insurance Research Database (NHIRD) for the years 2008 through 2012. By analyzing this population dataset, the study illustrates the disease landscape of emergency eye care services. The five-year, one-million-person NHIRD sub-dataset for 2008 through 2012 was used to explore emergency visits and ophthalmology specialty visits and to analyze the associated demographics and diagnosis codes based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Diagnoses were categorized into three groups: urgent, non-urgent, and intermediate. A total of 2454 emergency eye care visits were identified. The mean age of the patients who made these visits was 34.6 years old, and their sex ratio was 1.36 men to women. The percentages of urgent, non-urgent, and intermediate eye care visits in this study were 48.2%, 30.9%, and 20.9%, respectively. The leading diagnoses in the urgent category were corneal abrasions, foreign bodies in the eyes, eye burns, and blunt eye injuries. The leading diagnoses for the non-urgent visits were conjunctivitis, subconjunctival hemorrhages, trichiasis, and dry eye disease. Those for the intermediate category were superficial punctate keratitis, corneal opacity and degeneration, and lid, orbital, and lacrimal drainage infections. The urgent visit category accounted for nearly half of all the visits identified in this study. Compared to outpatient department visitors, the emergency ophthalmology service patients were younger and more predominantly male. These results were consistent with those of previous reports. Low copays have made emergency ophthalmology services highly accessible in Taiwan. However, future policies can be designed to more effectively allocate resources to urgent cases.

Factors Responsible for Poor Visual Outcome Following Emergency Eye Surgery in a Tertiary Eye Centre

Background

Ocular emergencies can cause permanent vision loss if they are not recognized and treated promptly. This study was carried out to identify the factors responsible for poor visual outcome following emergency eye surgeries.

Methods

A cross-sectional study was carried out on all patients who had surgical emergency eye procedures. Clinic and theatre records of all eligible patients were retrieved. Demographic characteristics, duration of symptoms, laterality, presenting visual acuity, documentary pictures, classfication of eye injury, duration of days before surgery, surgical procedures performed and six weeks post-operative visual acuity were obtained from the records. Data were analyzed using Statistical Package for Social Sciences, version 25.

Results

One hundred and ninety-four patients had emergency eye surgical procedures constituting 16.3% of all ocular emergencies. There were 145(74.7%) males and 49 (25.3%) females with a male-to-female ratio of 3:1. The proportion of students, 48(67.6%), that presented within 24 hours of injury was the highest while the civil servants, 8(17.8%), had the lowest proportion. Corneo-scleral repair topped the list of surgeries and was the commonest, 106(54.6%), procedure carried out the same day of presentation. A 3^rd of the patients, 28(34.1%), who presented within 24 hours had normal vision 6 weeks post-operatively while over 4/5^th of the patients who presented after 24 hours were blind six weeks post-operatively.

Conclusion

The prevalence of eye emergency surgical procedures was high with over 4/5^th of these patients becoming blind six weeks post-operatively. Some of the factors responsible for poor visual outcome were delayed presentation, pre-operative visual acuity and delayed surgical intervention.

Intraocular metallic foreign body: role of computed tomography

Orbital foreign bodies remain a serious diagnostic problem, despite development of diagnostic imaging techniques. Non-metallic orbital foreign body will not be detected in routine x-ray. Here we are presenting a case of 32-year-old male presented with acute pain in left eye immediately after he had been pounding a metal object with a metal chisel. Following this event patient develop blurring of vision in left eye with tearing. Patient's vision in left eye was found to be hand motion with conjunctiva mildly injected, left corneal central 1 mm Seidel-negative full-thickness laceration and dense traumatic cataract was seen on ocular examination. Dilated fundus examination of left eye was not possible due to traumatic cataract. Vitreous hemorrhage, vitreous detachment and a echogenic foreign body present in posterior segment in B-Scan sonography. Well-defied hyperdense foreign body producing streak artifacts with vitreous hemorrhage was seen in the posterior chamber of left eyeball in CT orbit. The patient was diagnosed with a corneal laceration, traumatic cataract, vitreous hemorrhage and a metallic intraocular foreign body. He was brought to the operating room urgently for corneal laceration repair, pars plana vitrectomy, lensectomy, and removal of the metallic intraocular foreign body done.

Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial

OBJECTIVES

The objective of this study was to test the hypothesis that topical tetracaine would be safe to use for 24 hours and would not affect corneal healing, that patients would experience more pain relief, and that patients would perceive tetracaine to be more effective than saline eye drops for the treatment of pain caused by corneal abrasions.

METHODS

The study was a 12-month, prospective, double-blind, randomized trial of tetracaine versus saline set in the emergency department (ED) of a regional tertiary care teaching hospital. A total of 116 patients presenting with uncomplicated corneal abrasions were included in this study. The intervention was either undiluted, preservative-free, topical tetracaine hydrochloride 1% or saline, applied up to every 30 minutes while awake for 24 hours. Main safety outcome measures were repeat ED examinations at 48 hours with fluorescein staining and slit-lamp examination, 1-week and 1-month telephone interviews with additional examinations as needed, and monitoring of charts for complications. Secondary outcome measures were 100-mm visual analogue scale (VAS) pain scores recorded every 2 hours while awake for 48 hours and patient-perceived overall effectiveness using a numeric rating scale (NRS) of 0 to 10 obtained during telephone interviews.

RESULTS

At least one follow-up encounter was completed on each of the 116 patients. No complications specifically attributed to topical anesthetic use occurred in the 59 patients in the tetracaine group, and the binomial probability confidence interval (CI) of this occurring is 0 to 6.1. There was no significant difference in corneal healing as measured by the percentage of patients with persistent fluorescein uptake at 48 hours between the two groups (23.9% vs. 21.3%, difference=2.6%, 95% CI=-14% to 20%, p=0.761) or persistent symptoms at 48 hours (21.7% vs. 21.3%, difference=0.4%, 95% CI=-16% to 17%, p=0.957). There was no clinical difference in VAS pain scores between the groups. Patients in the tetracaine group rated the study drugs' overall effectiveness significantly higher on the NRS (7.7 vs. 3.9) compared to patients in the saline group (difference=3.9, 95% CI=2.4 to 5.3, p<0.0005).

CONCLUSIONS

Topical tetracaine used for 24 hours is safe, and while there was no significant difference in patient VAS pain ratings over time, patient surveys on overall effectiveness showed that patients perceived tetracaine to be significantly more effective than saline.

A prospective observational study of techniques to remove corneal foreign body in the emergency department

INTRODUCTION

Patients  with corneal foreign bodies (CFBs) often present to the emergency department (ED). However, removal techniques vary among emergency physicians (EPs). A prospective, single-blinded, observational study was performed to compare slit-lamp-aided (SLA) versus non-slit-lamp-aided (NSLA) CFB removal by EPs.

METHODS

Five EPs enrolled consecutive patients with a CFB over 3 months. One blinded EP reviewed patients after 3 days. The study end points were: change in visual acuity; visual analogue pain scale (VAS) score at 12 and 24 h; satisfaction rating; symptoms at follow-up; and rate of complications.

RESULTS

54 patients were enrolled: 28 had SLA removal and 26 NSLA removal; 52 were male; 22 had undergone previous CFB removal; six were wearing eye protection at the time of injury. Forty-three patients were reviewed: 26 by attendance and 18 by telephone. There was no difference in any end points at review. However, patients in the SLA group had median VAS scores that were 1.5 cm lower after 24 h than patients in the NSLA group (p=0.43, 95% CI -2.0 to 1.0). One patient in the SLA group developed keratitis.

CONCLUSIONS

We show that patient satisfaction ratings, complications and visual acuity were similar for the two methods. There was a trend for increased pain in the NSLA group at 12 and 24 h. Slit-lamp biomicroscopy and the use of magnification to remove CFBs remains the gold standard of care, and more intensive training should be given to EPs at the departmental level, particularly in EDs that receive patients with eye injuries.