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Triage of the Ophthalmic Patient

Triage of the Ophthalmic Patient

R E F I N E M E N T SClinical Education ModulesContinuing Education

Rfor Today’s Ophthalmic Team

Triage 2nd Edition November 2008
of the
Ophthalmology REVIEWERS
David K. Coats, MD
Ashvini K. Reddy, MD
Alma Sanchez, COA

Module 0027

Triage of the Ophthalmology

JCAHPO neither endorses nor supports any manufacturer, producer,
supplier, or product mentioned in this module.

Table of Contents Editor

INTRODUCTION .....................................................................1 Karl C. Golnik, MD
Telephone Triage .................................................................1 JCAHPO Education Committee

Telephone Etiquette Karl C. Golnik, MD, Chair
Basic Information Laurie K. Brown, COMT, COE
History .....................................................................................3
Barbara T. Harris, COA
Loss of Vision...........................................................................3 Judy E. Kim, MD

Pain in and Around the Eye .................................................4 Natalie Loyacano, COMT, ROUB, OCS
Elbert H. Magoon, MD
Redness and Discharge.............................................................5
Craig Simms, COMT, ROUB
Double Vision...........................................................................6 Jeanine Suchecki, MD

Flashes and Floaters .................................................................7 Reviewers

White Pupil...............................................................................7 Melvin I. Freeman, MD, FACS
Karl C. Golnik, MD
Eye Trauma ..............................................................................7
SUMMARY .............................................................................8 Previous author contributions by: Gina R. Rosby, CO and Andrew G. Lee, MD
NOTE ...................................................................................9
REFERENCES & SUGGESTED READING ....................................9 Disclaimer Statement
EXAMINATION QUESTIONS ................................................9-10
This material is produced for educational purposes only. Course material is based on the
author(s)' interpretation of the content areas presented. JCAHPO disclaims responsibility
and liability for any adverse medical or legal effects, including personal, bodily, property,
or business injury, and for damages or loss of any kind whatsoever, resulting directly or
indirectly, whether from negligence or otherwise, from the use of recommendations or
other information in this module, from undetected printing errors or recommendation
errors, or from textual misunderstandings by the reader.

Any information contained in this module relating to medical conditions or medication is
provided solely for informational purposes and is not intended for diagnostic purposes.
Refinements are not intended to offer medical advice or diagnosis of medical conditions
or to be used as a substitute for consultation with a physician or other health care
practitioner. You should always consult with a physician or other health-care provider with
any questions relating to medical conditions or medication. JCAHPO makes no
representations or warranties relating to the information contained in this module and
JCAHPO will not be liable for the use or results obtained from this resource.

Caution is especially urged when using new or infrequently used drugs. Including all
indications, contraindications, side effects, and alternative agents for each drug or
treatment is beyond the scope of this module.

All photos in this publication, unless noted otherwise, are courtesy of the American
Academy of Ophthalmology. Cover photo (top left) courtesy of W. K. Kellogg Eye
Center, University of Michigan.

AAO 1st Edition 2000; JCAHPO 2nd Edition 2008

Refinements Clinical Education Modules for Today's Ophthalmic Team is published by the Joint Commission on Allied Health Personnel in Ophthalmology, Inc®,
2025 Woodlane Drive, St. Paul, MN 55125. Editorial revisions to this module may have been made based on reviewer recommendations. Copyright 2008 JCAHPO®.
All rights reserved. Each author states that he or she has no significant financial interest or other relationship with the manufacturer of any commercial product discussed in
this module or with the manufacturer of any competing commercial product unless so indicated.

REFINEMENTS #27 / November 2008


A busy ophthalmology practice is bombarded daily with calls from patients concerned about the health
of their eyes. The importance and urgency of patient calls vary, ranging from the routine (for example,
scheduling a routine appointment) to the emergent (for example, asking about an acute, painful, blind
eye). Ophthalmic medical personnel—technicians, nurses, and others—are often the first line of
communication for these patients; as such, they should be aware of the key symptoms that separate
urgent and emergency problems from those that are routine and can wait.

Emergency ophthalmologic problems are those that need immediate attention. Patients with such
problems should be advised to come to the office or emergency room (depending on the nature of the
problem) immediately. Urgent ophthalmologic problems are serious conditions requiring evaluation
within 12–24 hours.

This module is divided into sections based on major groups of signs and symptoms. The significance of
each individual sign or symptom is discussed and guidelines regarding appropriateness of the timing of
the evaluation are provided. Special considerations for pediatric patients are presented as well.


Upon completion of this module, the reader should be able to:

(1) describe the purpose and process of patient triage.
(2) explain and demonstrate proper telephone etiquette.
(3) identify potentially sight- and/or life-threatening disorders.
(4) identify specific urgent or emergency ophthalmologic problems.
(5) explain the significance of common signs and symptoms described by patients.
(6) differentiate and prioritize among emergency, urgent, and routine calls.

Telephone Triage or department, and patients judge an office’s
reputation and professionalism by this call. Indeed, it
Triage is the evaluation, classification, and may be their first contact with the ophthalmologist’s
prioritization of patient need for and order of office. This first impression is an extremely important
treatment. Triage is necessary because an office has reflection of the office and its staff, and may set the
only a limited number of appointment slots each day, tone for future interactions.
and patient visits must be prioritized according to
need, with more urgent problems getting priority. In general, it is important to answer the telephone as
quickly as possible. Answering within the first two
An effective triage system should be able to efficiently rings is ideal. An unanswered call (“dropped call”) is
identify potentially sight-threatening and/or life- lost information and perhaps a lost patient. The
threatening disorders, and should provide for timely following are the “Do’s” of telephone etiquette:1
and appropriate evaluation. Patients should be
divided into categories and prioritized for evaluation 1. Do smile when answering the telephone (Smiling
(for example, routine, next available, overbook, puts “a smile in your voice” that is perceptible to the
urgent, emergency). Effective telephone triage begins caller on the other end of the line). At the same time,
with proper data collection and appropriate etiquette. convey concern by your manner.

Telephone Etiquette 2. Do remove distracting items and avoid performing
other duties during the telephone call so that you can
Ophthalmic medical personnel should be polite and devote your undivided and complete attention to the
professional at all times. Staff members talking with caller. Callers can hear if you are typing on the
patients on the telephone represent the entire office computer, eating, or shuffling papers on your desk.

1 REFINEMENTS #27 / November 2008

3. Do have a pen and paper handy to answer and leave callers with the impression that nothing is being
record questions. Keep relevant telephone numbers, done to help them.
addresses, transfer information, calendar, and other
relevant information near the telephone to avoid If the call is going to be transferred, tell the caller the
wasting time or putting the caller on hold while name and number of the person to whom he or she is
trying to find this information. being transferred (in case you are disconnected).

4. Do always begin the telephone call with a The following are the “Don’ts” of telephone triage:1
greeting (for example, “Good morning, [state
your office or department name], my name 1. Don’t interrupt the caller. If interruption is
is...How can I help you today?”). absolutely necessary, always say “Excuse me” and use
the caller’s name. Always address the caller as “sir” or
5. Do obtain screening information first. The basic “madam.” Always say “please” and “thank you”
information includes: (1) the caller’s name, (2) the during the conversation.
relevant information about the caller in relation to
your office or department (for example, the caller is a 2. Don’t argue with the caller (mentally or verbally)
physician, patient, other), and (3) the nature of under any circumstances.
the call.
3. Don’t raise your voice.
6. Do triage by complaint: The most important questions
after the baseline information are: 4. Don’t give the caller the impression that the
Is this an emergency? Is this urgent? Is this something problem is her or his fault in any way.
the doctor needs to know about now?
5. Don’t leave the problem unresolved. (Instead say: “I
7. Do triage by person. Most offices will directly am sorry, I can’t help you with that problem, but if
connect an outside physician who calls a physician in you leave your name and number I will find someone
the office, regardless of the problem. This will vary who can help you.”)
from office to office, but in general it is a good idea
from both a medical and professional standpoint. If a 6. Don’t place the caller on hold unless it is
physician is taking the time to call your office, it absolutely necessary.
usually is an important issue.
7. Don’t work on other projects while talking to
8. Do listen to the caller and be empathetic to her or the caller.
his problem. (Sick patients are looking for comfort;
urgent or emergency patients are looking for action.) 8. Don’t use the speakerphone.

9. Do offer to help in any way you can (If you are not the 9. Don’t forget that the person calling is often worried,
person to help them, then find the person who can). sick, or in need of help.

10. Do remain patient. 10. Don’t tell the patient you cannot help her or him.

11. Do speak slowly and enunciate your words. Speak in If the caller must be placed on hold, remember to ask
conversational tone and volume; speak as if the first. Never “tell” the patient to hold and do not
patient were seated across from you. answer the telephone with “Please hold” without
talking to the caller. Before putting a patient on hold,
12. Do speak in a professional manner with proper tell her or him exactly what you are doing. Then wait
grammar and vocabulary. for a reply before you do so (if it is an emergency,
give the caller an opportunity to tell you why she or
13. Do be polite (even if the caller is not). he cannot hold). When you come back to the person,
thank him or her for holding. Normally, 30–40
14. Do pull the patient’s chart if the question requires seconds is an acceptable holding time (but remember
medical information. that 30 seconds on hold may feel like 30 minutes to
the caller). If the hold time is longer than 1 minute,
After the baseline information has been obtained, return to the line and apologize for the delay. Explain
consider your next step. If the call is not an that the task is taking longer than you expected and
emergency or is not urgent, and the person who is thank the caller again for waiting. If the hold time is
being called is not available, it is normally sufficient insufficient to reach the intended individual or
to explain the situation, ask if the caller would like to complete the task, take down the caller’s name,
leave a name and number, and then be sure the number, and message.
message reaches the individual in question. Do not

REFINEMENTS #27 / November 2008 2

Basic Information Figure 1. Central retinal artery occlusion with retinal
whitening (ischemia) and “cherry-red spot” in the macula.
The following basic information should be
documented for all telephone messages (Your to be able to recognize those patients with urgent or
employer may have specific items they want as well):1 emergency treatable problems.

1. The caller’s full name (with correct spelling and The first and most important issue for patients with
phonetic pronunciation if unusual). vision loss is severity. Questions should include:

2. The caller’s telephone number, including the area code. • How bad is your decreased vision?

3. The date and time of call. • What can you see? Can you read? Count fingers? See
hand movement? Light only? No light perception?
4. The intended receiver for the call.
Although any degree of reduced vision should be
5. The urgency or nonurgency of the call (see the taken seriously, rapid and/or severe visual
following sections for appropriate questions to ask). impairment should put ophthalmic medical personnel
on high alert. Acute onset of severe vision loss is
6. The call disposition (for example, “will call back,” usually an emergency condition and requires
“requests call back,” “for your information,” “call immediate evaluation.
back between 1–2 PM”).
The second issue is timing. Questions should focus
7. The complete message, including the relation of the on the onset and timing of the vision loss:
caller to the office (for example, physician, patient,
or other). • Did this happen suddenly? Or did the patient suddenly
become aware of an existing problem?
8. Your signature and printed name.
• How long has the vision been reduced? Is vision
9. Clear, concise, and legible documentation. becoming worse?

All relevant information in the medical triage setting Ophthalmic conditions that can cause acute vision
should be written down. (Never rely on your memory loss include central retinal artery occlusion (Figure
alone). Preprinted telephone message forms with 1), central retinal vein occlusion, optic neuritis,
copies are ideal. ischemic optic neuropathy, giant cell arteritis, angle-
closure glaucoma, and retinal detachment. Table 1
History lists possible causes of acute vision loss.

The following basic questions help to determine the All patients who complain of acute vision loss should
seriousness of a patient’s problem: be advised to come to the office or emergency room
immediately for evaluation. The check-in desk should
• What is the problem? Loss of vision? Double vision? be advised that the patient is coming, the previous
Pain? Discharge? Flashers and floaters? White pupil? chart should be available, and the doctor should be
notified. Patients with acute vision loss may need to
• When did the problem start? Is it getting better bypass the routine office registration process and
or worse? paperwork if the condition is deemed an emergency.

• Which eye is affected? One eye or both eyes?

• Is pain present? If yes, is it mild, moderate, or severe?

• How bad is the problem? Mild? Moderate? Severe?

• Is there a history of eye disease? Eye surgery?
Eye injury?

Loss of Vision

Reduced vision is a common presenting complaint
and can occur as an acute (sudden) or chronic
(ongoing) process. Vision loss may be due to serious
causes (for example, retinal detachment, optic
neuropathy) or benign causes (for example, refractive
error). Unfortunately, “decreased vision” alone is a
common and non-specific complaint. It is important

3 REFINEMENTS #27 / November 2008

Table 1 Special Pediatric Considerations: Poor vision
during the learning years can adversely impact
Possible Causes of Acute Vision Loss school performance and learning. It is, therefore,
considered by many to be a developmental
Anterior segment emergency, and children with reduced vision should
Corneal hydrops (as in keratoconus) be evaluated as soon as practical. Young children
Corneal edema (acute glaucoma) may not be aware or complain of vision loss,
especially if it is monocular. Behavioral changes may
Retinal disorders be apparent if vision loss is bilateral; however,
Retinal detachment monocular vision loss is often missed until the
Branch or central retinal artery occlusions child’s first vision screening. Amblyopia in young
Branch or central retinal vein occlusions children is always a potential concern and early
diagnosis and treatment are imperative to eventual
Optic nerve problems visual recovery.
Optic neuritis
Anterior ischemic optic neuropathy Pain in and Around the Eye
Traumatic optic neuropathy
Pain is always a sign of potentially serious
Systemic disease ophthalmologic disease and should never be
Giant cell arteritis (optic neuropathy) considered normal. Pain symptoms can vary from
Multiple sclerosis (optic neuritis) mild to severe and can be acute or chronic,
intermittent or constant. Ophthalmic technicians
Some conditions, such as central retinal artery should attempt to ascertain important information
occlusion or angle-closure glaucoma, may have a about the patient’s pain:
poorer outcome if treatment is delayed. Patients who
have undergone recent eye surgery and have vision • How bad is the pain? Is it sharp? Aching? Throbbing?
loss should be seen on an emergency basis to exclude
surgical complications such as endophthalmitis. • Is the pain located in the eye? Is there headache or
scalp tenderness?
For patients who complain of more insidious loss of
vision, such as the slowly progressive loss typical of • When did it start? Was there an inciting event, such as
cataract formation, the ophthalmic technician should trauma? Is vision adversely affected? Is there associated
try to ascertain how long the problem has been ocular redness or discharge?
developing. A gradual reduction in vision that has
occurred over several months may still be caused by a Many causes of eye pain pose a serious risk to the eye
vision-threatening disorder, but it does not typically and sometimes to the patient’s systemic health. In
require emergency evaluation. In general, patients general, patients who present with pain that is
with chronic vision loss that is worsening should be moderate or severe should be seen that day. Eye pain
evaluated as soon as possible—usually within a few in a patient who wears contact lenses or following
days. This recommendation, however, will vary from even a minimal trauma, such as brushing the eye with
practice to practice. a branch while gardening, may indicate a corneal
epithelial abrasion. Although a corneal abrasion can
Not infrequently, a patient will cover one eye and heal rapidly, there is significant risk of infection
discover poor vision in the opposite eye. Such a patient progressing to a corneal ulcer or perforation. Eye
will often call and complain of acute vision loss. In pain plus vision loss (for example, uveitis) or eye pain
reality, the patient has not experienced acute onset, but plus redness (for example, scleritis) always demand
rather acute awareness of reduced vision in one eye. It urgent assessment and treatment to prevent
is often difficult to determine if such a patient truly has permanent ocular damage. A patient with eye pain
acute vision loss or simply has suddenly discovered a plus scalp tenderness and/or pain in the jaw must be
long-standing problem by covering her or his better- seen on an emergency basis, as this may indicate giant
seeing eye. It is usually prudent, therefore, to see such cell arteritis with its risk of vision loss and serious
patients on an emergency or urgent basis to rule out a systemic illness. Patients with eye pain who have
potentially treatable problem. undergone recent intraocular surgery should be seen
on an emergency basis as well, as this may indicate
infection or endophthalmitis. Table 2 lists common
causes of acute eye pain.

REFINEMENTS #27 / November 2008 4

Patients with chronic mild discomfort can usually be a
seen on a routine basis. For example, a patient with a
six-month history of burning eyes is likely
experiencing an ocular surface problem such as dry
eyes or blepharitis and need not be seen urgently. It
is important to remember, however, that any time a
question exists, the ophthalmologist should be
consulted for her or his recommendations. A patient
who calls to complain of eye pain should be advised
not to rub the affected eye. This is especially
important for patients who have undergone previous
eye surgery or who have suffered ocular trauma.

Special Pediatric Considerations: Young children
may not be able to complain of pain. Persistent
crying, eye rubbing, blinking, and redness may be
the only signs of eye pain in preverbal children.

Redness or Discharge b

Any patient who calls to complain of redness or Figure 2. Red eyes. a. Conjunctival injection in a patient with
discharge should be taken seriously. Unfortunately, iritis; b. spontaneous subconjunctival hemorrhage.
“redness” is a common but non-specific sign of
ocular disease. Redness of the eye may be due to Subconjunctival hemorrhages are quite common and, by
dilated blood vessels in the conjunctiva (injection), themselves, are harmless. They resolve spontaneously
episclera, or sclera, or it may be due to blood without treatment within 7–10 days. An antecedent
underneath the conjunctiva (subconjunctival history of trauma or a history of pain associated with a
hemorrhage; Figure 2). Table 3 lists the common subconjunctival hemorrhage, however, demands immediate
severe causes of the “red eye.” evaluation. Spontaneous subconjunctival hemorrhages
often occur because of straining or coughing and are not
Table 2 painful. If a patient calls to complain that her or his eye
is red, ask if the blood vessels are dilated or if there
Common Causes of Acute Eye Pain appears to be a hemorrhage present. If the condition
sounds like a typical subconjunctival hemorrhage and
Anterior segment there is no vision loss or pain, then a routine eye
Corneal abrasion appointment is reasonable; however, despite
Foreign body reassurances, many patients with subconjunctival
Corneal ulcer hemorrhage are so alarmed by the appearance of their
Iritis eye that they might benefit from being seen earlier. In
Acute angle-closure glaucoma such a situation, it is better to err on the side of
caution and have the patient come into the office
Posterior segment for evaluation.
Optic neuritis
Scleritis Redness of the conjunctiva, episclera, or sclera can be
caused by a variety of diseases. Conjunctivitis can be
Orbit caused by irritation, dry eyes, or a foreign body.
Trauma Redness can also be caused by an infectious condition
Neoplasm (for example, adenovirus) or an autoimmune
Orbital pseudotumor condition (for example, episcleritis or scleritis).
Photophobia, pain, significant discharge, or vision
loss should prompt urgent evaluation. Acute redness
of the eyes without these associated signs is
commonly caused by benign entities that may

5 REFINEMENTS #27 / November 2008

Table 3 Figure 3. Right eye does not abduct completely due to a right
sixth nerve palsy.
Common Causes of Red Eye
Requiring Urgent Evaluation system disorders. A patient with acute-onset binocular
diplopia should be seen on an urgent basis (within 24
Trauma hours); if pain and/or a droopy lid (ptosis) are
Conjunctivitis/Keratoconjunctivitis associated, the situation should be treated as an
Episcleritis emergency. To ascertain whether the problem is acute
Scleritis or chronic, the patient needs to be questioned
Angle-closure glaucoma carefully so that the information necessary to fully
Uveitis assess the situation is obtained. Standard questions
include the following:
nonetheless require evaluation within the week (for
example, adenoviral conjunctivitis). Early diagnosis • When did the double vision begin?
can help stop the spread of some highly-infectious
conditions to other people. • Does the double vision go away if one eye
is covered?
Patients who complain of painless, chronic ocular
redness with normal vision are not typically at risk for • Is it up and down (vertical) or side by side (horizontal)?
an immediate vision-threatening problem and can
usually be worked into the routine schedule. For • Is there any pain?
example, a 56-year-old male who complains of
intermittent redness in his eyes for the past 3 months • Is there any lid drooping?
is likely suffering from a less serious problem, such as
dry eyes, and can safely be worked into the routine • Are other neurologic signs or symptoms present,
schedule. It is important, however, to confer with the suchas weakness, difficulty swallowing, or speaking?
ophthalmologist any time the history is in question or
uncertainty exists. • Have you ever had this problem before? Is there a
history of strabismus?
Special Pediatric Considerations: When a small child
has subconjunctival and/or eyelid hemorrhages, • Is there any associated pain or dullness of vision?
ophthalmic medical personnel should always suspect a
serious problem and schedule an evaluation for as soon • Do you have diabetes or high blood pressure?
as possible. Potential problems include metastatic
cancer, such as neuroblastoma; accidental trauma; and Answers to these questions will help to decide how
child abuse. and when to schedule the patient with diplopia. A
patient with a history of strabismus and intermittent
Double Vision diplopia for months or years does not usually have a
vision- or life-threatening problem and, therefore,
The main objective when triaging a patient with can be legitimately worked into the routine schedule.
double vision is to attempt to identify those patients On the other hand, a patient with no history of
with a potentially serious neurologic problem (such as strabismus who complains of acute-onset diplopia,
patients with cranial nerve palsies or associated with or without accompanying pain, requires urgent
neurologic symptoms). evaluation. Table 4 lists some causes of
acute diplopia.
The presence of acute-onset binocular diplopia—that
is, diplopia that resolves with covering either eye— 6
whether horizontal, vertical, or torsional (that is, one
eye’s image is tilted), should prompt concern. A palsy
of cranial nerves III, IV, or VI may produce acute
diplopia (Figure 3). Such cranial nerve palsies can
occur as isolated events in patients with hypertension
and diabetes, but they may also be presenting signs in
patients with brain tumors and other central nervous

REFINEMENTS #27 / November 2008

Table 4 Eye Trauma

Common and Uncommon but Serious Unfortunately, eye trauma is common. It can occur in
Causes of Acute Diplopia patients of any age and may lead to permanent vision
loss. All calls from patients reporting eye trauma
High blood pressure should be handled as priority calls. The mechanism of
Diabetes injury is an important piece of information that will
Giant cell arteritis aid ophthalmic medical personnel in assessing risk
Myasthenia gravis and in providing triage.
Other neurologic problems
Brain tumor, stroke Injuries associated with sharp objects such as glass or
knives should raise concern that the eye may be
Special Pediatric Considerations: Double vision in lacerated. Blunt trauma, such as that caused by a fist
a child should always prompt serious concern, or baseball, may lead to such serious problems as
regardless of the timing of onset. Evaluation should hyphema (blood in the anterior segment of the eye
proceed on an urgent basis. Figure 6) or open globe. Pain that occurred while the
patient was using a hammer, drill, lawn mower, or
Flashes and Floaters
Figure 4. Retinal detachment in a patient complaining of
Complaints of flashes of light or significant new flashes and floaters.
floaters (for example, “cobwebs, dust, black spots in
my vision”) suggest the possibility of retinal disease. Figure 5. Leukocoria in a child with retinoblastoma.
The most common cause of acute flashes and floaters
is a posterior vitreous detachment (PVD). A retinal Figure 6. Hyphema.
hole or tear may or may not accompany a posterior
vitreous detachment in the weeks immediately REFINEMENTS #27 / November 2008
following its occurrence. The development of an
acute PVD puts the patient at increased risk of
developing a retinal detachment (Figure 4). It is
impossible to tell, through the history alone, whether
an impending or existing retinal detachment is
present. The patient who complains of flashes and
floaters should be questioned as to the onset and
frequency of symptoms. If symptoms have been
occurring without change for weeks or months, the
patient can be legitimately worked into the routine
schedule. If the flashes and floaters are of new onset
or have been present for some time but have suddenly
worsened or changed in character, (for example, they
occur more frequently, they occur as a shower of
floaters or as a visual field defect) then prompt
evaluation is recommended.

White Pupil

A white pupil, or leukocoria, is always a sign of a
serious vision- or life-threatening problem in a
pediatric patient. The most serious cause of
leukocoria is a retinoblastoma (Figure 5). This tumor,
the most common intraocular malignancy in
childhood, typically has a white, chalky appearance.
Other causes of leukocoria include cataracts, severe
retinal detachment, and toxocariasis (infection by the
larvae of the Toxocara canis worm), among other
causes. A child with a white pupil should be handled
urgently (within 24 hours).


Figure 7. Alkali burn; blanching of the conjunctiva. Table 5

other powered device capable of ejecting a small Triage Situations
metallic fragment at high speed may not be severe or
last long, but such injuries may be associated with Emergencies
severe injury and even blindness if not recognized • Chemical burns: alkali, acid, or organic
and treated effectively. Patients with ocular injuries
should be advised to come immediately to the office solvents in the eye
or nearest medical center capable of managing • Sudden, painless, severe loss of vision
ophthalmologic diseases. They should be advised not • Trauma in which the globe has been or is
to touch or rub the injured eye. It is important to
know that a serious injury might be present even if likely to be disrupted or penetrated
vision is normal and there is no pain. • Any trauma associated with vision loss or

Chemical injuries require special attention. When a persistent pain
chemical, such as bleach, acid, or an unknown • Severe blunt trauma, such as a forceful blow
substance, has been splashed or sprayed into an eye,
the potential for serious injury is very high (Figure with a fist or high-velocity object such as a
7). Immediate irrigation with water at the scene of tennis ball
the accident may dilute and wash the substance from • A foreign body in the eye or a corneal
the eye and reduce the amount of injury that occurs. abrasion caused by a foreign body
Patients with a history of chemical injury to the eyes • Acute, rapid onset of eye pain or discomfort
should, therefore, be advised to flush their eyes
immediately for several minutes. They should then be Urgencies
taken immediately to the nearest medical facility • Subacute loss of vision that has evolved
capable of managing an ophthalmologic emergency.
gradually over a period of a few days to a week
Summary • Sudden onset of diplopia or other distorted

Telephone triage is one of the most important vision issues
activities in which ophthalmic medical personnel may • Recent onset of light flashes and floaters
be involved. See Table 5 for a summary of triage • Acute red eye, with or without discharge (In
situations. The role of triage is to establish the
seriousness of the caller’s problems and to ask some patients, such as contact lens wearers,
appropriate questions to determine if the patient this may be an emergency.)
needs to be evaluated urgently or on a routine basis. • Blunt trauma, such as a bump to the eye,
Ophthalmic medical personnel must be knowledgeable that is not associated with vision loss or
about a wide variety of topics and understand the persistent pain and where penetration of the
potential implications of a broad spectrum of symptoms. globe is not likely
Following proper procedures and practicing telephone • Double vision that has persisted for less than
etiquette are essential to ensuring patient satisfaction and a week
to ensuring accurate triage of each patient. • Photophobia (sensitivity to light)
• Progressively worsening ocular pain

Routine Situations
• Discomfort after prolonged use of the eyes
• Difficulty with near work or fine print
• Mild ocular irritation, itching, burning
• Tearing in the absence of other symptoms
• Lid twitching or fluttering
• Mucous discharge from the eye
• Mild redness of the eye not accompanied

by other symptoms
• Persistent and unchanged floaters whose

cause has been previously determined

REFINEMENTS #27 / November 2008 8

David K. Coats, MD, is Assistant Professor of Note
Ophthalmology at Baylor College of Medicine,
Houston, Texas. 1. Telephone Etiquette. The University of Iowa Office of
Staff Development and Training Manual, 1987.
Ashvini K. Reddy, MD, is a resident-in-training at Modified with permission.
Baylor College of Medicine, Houston, Texas.
References and Suggested Reading
Alma Sanchez, COA, is a Certified Ophthalmic
Assistant at Texas Children’s Hospital in American Academy of Ophthalmology: Preferred Practice
Houston, Texas. Pattern: Comprehensive Adult Eye Evaluation. San
Francisco: American Academy of Ophthalmology; 2005.

American Academy of Ophthalmology:Preferred Practice
PatternPediatric Eye Evaluations. San Francisco:
American Academy of Ophthalmology; 2007.

Basic and Clinical Science Course. (BCSC) Section 6:
Pediatric Ophthalmology and Strabismus. San Francisco:
American Academy of Ophthalmology; 2007-2008.

Newmark E, ed: Ophthalmic Medical Assisting: An
Independent Study Course. 4th ed. San Francisco:
American Academy of Ophthalmology; 2006.

Stein HA, Stein RM, Freeman MI: The Ophthalmic
Assistant: A Text for Allied and Associated Ophthalmic
Personnel. 8th ed. Philadelphia: Elsevier/Mosby; 2006.

Wilson FM, ex.ed: Practical Ophthalmology: A Manual
for Beginning Residents. 5th ed. San Francisco:
American Academy of Ophthalmology; 2005.

9 REFINEMENTS #27 / November 2008

REFINEMENTS Clinical Education Modules for Today’s Ophthalmic Team

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