Patricia M O'Connor, PhD, Research Fellow; Carmel T Crock, MB BS, FACEM, Emergency Physician; Rana S Dhillon, MB BS, Neurosurgery Registrar; Jill E Keeffe, OAM, PhD, Principal Research Fellow (Professor) and Unit Head.
Review article: Resources for the management of ocular emergencies in Australia
Version of Record online: 7 APR 2011
© 2011 The Authors. EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia
Volume 23, Issue 3, pages 331–336, June 2011
How to Cite
O'Connor, P. M., Crock, C. T., Dhillon, R. S. and Keeffe, J. E. (2011), Review article: Resources for the management of ocular emergencies in Australia. Emergency Medicine Australasia, 23: 331–336. doi: 10.1111/j.1742-6723.2011.01411.x
- Issue online: 14 JUN 2011
- Version of Record online: 7 APR 2011
- Accepted 11 February 2011
- emergency medicine;
- eye injury
The aim of the present paper is to assess the practical utility of the most common print resources used by practitioners in the management of ocular emergencies. Ten print resources were identified for review (three specialty eye texts, six general emergency medicine texts and one general practice text). The main outcome measures used were the extent a text matched crucial skills criteria in clinical assessment and treatment, and usability. No single print resource addressed all criteria. Red flag systems for clinical assessment and ease of navigation were the best match areas. Only one text inadequately stressed red flag conditions and one text was not ranked as easy to navigate. All texts made assumptions regarding the knowledge/skill level of practitioners, particularly in relation to eye examination procedures and treatment. Photographs ranged in number from 8 to 1500; 3/10 texts provided no photographs. Five texts included detailed instructions on the indications and urgency of referral and follow up for all conditions covered. The remainder lacked details. Only one text used the Australasian Triage Scale. Three texts included photographs/diagrams and instructions for the slit lamp and ophthalmoscope. None covered all procedures specified in the criteria. Only two reflected drug current practice in Australia and provided adequate details on usage. A single comprehensive reference (print and/or web-based) for dealing with ocular emergencies in Australia is clearly needed. Additionally, training and confidence levels of eye care providers must be addressed so that the risk of misdiagnosis and mismanagement of eye emergencies is reduced.
Although many ocular emergencies can be vision-threatening, their symptoms are often more difficult to detect than life-threatening emergencies such as myocardial infarction or stroke. Indeed, patients' self-reported pain levels generally provide an unreliable basis upon which to distinguish between severe and minor ocular conditions. Painless emergencies can result in blindness whereas severely painful corneal abrasions are unlikely to do so. There is therefore an inherent risk of misdiagnosis or mismanagement of eye emergencies.
This situation is further complicated by the fact that ocular emergencies are dealt with by providers with different skills and experience levels. These include general practitioners (GP), optometrists, nurse practitioners and ophthalmic/emergency medical officers (interns, Hospital Medical Officers, ED registrars, ophthalmic registrars). Furthermore, equipment availability and practitioners' skill in the use of this equipment varies between these settings. For example, many GPs and nurse practitioners are unlikely to have access to a slit lamp. ED doctors might have access to a slit lamp but might lack the training or confidence in how to use it.1 Again, this increases the risk of misdiagnosis or mismanagement of eye emergencies.
Some diagnostic error is inevitable in the clinical setting. Elstein et al.'s estimate of 15% tends to be the accepted norm.2 However, a recent review of patient records in the ophthalmology departments at two Brisbane hospitals found that GPs had given incorrect initial diagnoses for 64.1% of the patients they had referred and 58.1% of the patients referred by ED doctors had incorrect initial diagnoses.3 These figures only relate to referred patients and might therefore not reflect the true proportion of misdiagnosis in the practitioners' total patient population.
Issues of confidence and training also underpin practitioners' approach to ocular emergencies. A 2005 survey of Victorian Fellows of the Australasian College for Emergency Medicine found that although physicians were confident in performing basic eye examinations, many lacked confidence in critical areas such as measuring intraocular pressure, assessing the depth of a corneal foreign body, identifying pathologies and in other areas where basic slit lamp examinations were required.4 A nationwide survey of emergency physicians in Australia found that ophthalmological emergencies ranked second among the topics most desired for continuing professional development, being listed by 92.6% of respondents.5
When the potential for misdiagnosis or mismanagement is translated into patient numbers, the scale of the issue is further emphasized. The Victorian Ophthalmology Planning Framework established that in 2002–2003, 397 408 GP attendances in Victoria were eye-related and a further 35 001 ophthalmology emergency presentations were reported by the 31 main Victorian public hospitals.6 Additionally, GP management of patients' vision problems often involves referral to secondary or tertiary services. In 2002–2003 GPs in Victoria generated 198 704 referrals to optometrists and 1 611 712 referrals to ophthalmologists. Eye-related conditions are therefore an important part of our health-care system.
The aim of the present paper is to assess the practical utility of the most common print resources used by practitioners in the management of ocular emergencies.
To assess the practical utility of each resource, a standard assessment template was developed (Table 1). The key questions developed for inclusion in this template were informed by the authors' expertise. Emphasis was placed on the crucial skills in clinical assessment and treatment that are needed to deal with eye emergencies if misdiagnosis and mismanagement are to be minimized. Usability factors were also considered. A preference was given to symptom-based content because topic-based content presupposes that the user is aware of what topic a particular symptom relates to and this might not actually be the case. Issues such as indexing and spread of content in text(s) were also reviewed as these could limit the comprehensiveness of the information available to the practitioner in an emergency setting.
|1. Clinical assessment||2. Treatment||3. Usability|
|1.1 Are red flags or some other mechanism used to alert the user to the signs and symptoms of all potentially serious conditions? 1.2 Are good-quality photographs included for all conditions covered? 1.3 Are indications for and urgency of referral and follow up included for all conditions covered? 1.4 Are sufficient instructions and clear photographs/diagrams included on the use of equipment, particularly the slit lamp and ophthalmoscope?||2.1 Procedures Are instructions provided on how to conduct all the following key procedures? • Lid eversion • Measurement of size of lesion • Measurement of intraocular pressure • Irrigation • Measurement of tear pH • Removal of corneal/conjunctival foreign body • Seidels's test • Lateral canthotomy/cantholysis 2.2 Medications Do the drugs listed reflect current practice and availability in Australia?||3.1 Is the information symptom-based rather than topic-based? 3.2 How easy is it to navigate? (locate the relevant information within the text)|
Ten commonly used print resources were identified for review. These comprised three specialty eye texts (#1–3),7–9 six general emergency medicine texts (#4–9)10–15 and one general practice text (#10)16 (Table 2). The composition of this list was established through a combination of the authors' experience and a telephone survey of medical officers in 10 metropolitan and 10 rural Victorian EDs.
|Red flags||Photographs of conditions||Referral and follow up||Equipment||All key procedures||Drugs||Symptom-based||Easy to navigate|
|1||The Wills Eye Manual7||✓||✓||✓|
|2||Oxford Handbook of Ophthalmology8||✓||✓||✓|
|3||Clinical Ophthalmology: A Systematic Approach9||✓||✓||✓||✓|
|4||Eye Emergency Manual (Sydney Eye Manual)10||✓||✓||✓||✓||✓||✓||✓|
|5||Emergency Medicine: A Comprehensive Study Guide11||✓||✓||✓|
|7||The Emergency Medicine Manual13||✓||✓||✓||✓|
|8||Textbook of Adult Emergency Medicine14||✓||✓||✓||✓|
|9||Rosen's Emergency Medicine Concepts and Clinical Practice15||✓||✓||✓||✓||✓|
For a text to be considered as having met these criteria, all elements specified for that criterion had to be included.
Each resource was independently reviewed by CC and RD. A high level of agreement was evident in each reviewer's assessment. Any mismatches were resolved through an iterative process that involved jointly re-visiting the text(s), discussing the rationale behind each assessment and reaching a mutually acceptable final assessment.
Table 2 lists how each of the commonly used print resources performed relative to the assessment criteria.
No single print resource was found to address all criteria. The areas of best concordance with the criteria were the use of red flag systems for clinical assessment and ease of navigation. Only one text was assessed as not having adequately stressed red flag conditions (#2)8 and one text was not ranked as easy to navigate (#10).16 All texts shared a common weakness in that assumptions were made regarding the knowledge/skill level of practitioners, particularly in relation to procedures for an eye examination and treatment.
In devising the criteria, good-quality photographs were considered as essential aids to clinical assessment. However, no photographs were provided in 3/10 texts. The photographic support available in the remaining texts varied. In terms of quality, photographic images ranged from black and white photographs (#5)11 to excellent colour photographs (#1, 2, 3, 6)7–9,12 with some intra-text variability in quality evident (#5, 9).11,15 The number of photographs ranged from 8 (#10)16 to 1500 (#3).9
Five texts provided detailed instructions on the indications and urgency of referral and follow up (#4, 5, 6, 9, 10) for all conditions covered. The remainder lacked details. The best description of indications for and urgency of referral of all the resources reviewed were found in #9.15
In Australian EDs, the Australasian Triage Scale is used to categorize emergencies in terms of clinical urgency.17 The Sydney Eye Emergency manual was the only reviewed resource to use this scale in discussing the conditions it covered (#4).10
Three texts (#2, 4, 6)8,10,12 included both photographs/diagrams and instructions for the slit lamp and ophthalmoscope, with the best slit lamp instructions found in #2.8 In the remainder, assumptions were made regarding familiarity with either or both pieces of equipment. As a result, limited or no instructions were provided.
From a treatment perspective, no text covered all the procedures necessary to assess and treat an eye emergency (Table 1). Coverage ranged from 6/8 conditions (#4)10 to 1/8 (#1).7 Assessment of drug recommendations was based on current practice in Australia and the provision of adequate details on drug usage. Only two texts satisfied both aspects of these criteria (#2, 3).8,9
In terms of usability, only one text (#4)10 was organized using a symptom-based approach throughout and a further three texts (#7, 8, 10)13,14,16 used both symptom- and topic-based approaches. Although the remainder were topic-based, two texts also included a symptom-based approach to one of the conditions they covered (#2, 5).8,11
Most texts (9/10) were easy to navigate. However, information on eyes were spread over two chapters in #10,16 thereby making it less easy to locate information in that text.
Although a range of print and on-line resources are used in the diagnosis and management of ocular emergencies, none of the print resources reviewed comprehensively addressed all of the crucial clinical assessment, treatment and usability criteria specified.
Issues of assumed knowledge were among the most common limitations of these resources. This was particularly evident where procedures and use of equipment were concerned. In dealing with eye emergencies, providers need to be confident and competent in performing a number of basic procedures. Most of the resources reviewed have insufficient instructions regarding the list of procedures specified in the methodology. Likewise, many resources either omitted or failed to include comprehensive instructions on how to use of the slit lamp and ophthalmoscope, fundamental prerequisites to establish/confirm diagnosis. References that assume procedural knowledge and lack good ‘how to’ photographs fail to provide all the crucial details on how to recognize and what to do when ocular emergencies present. Furthermore, topic-based resources assume that the user knows the relationships between particular symptoms and topics. The practical utility of texts and resources that presuppose prior knowledge in any of these areas is therefore limited.
Six of the 10 print resources commonly used in Australia were produced in either the UK or USA. As a result, the workforce arrangements, clinical assessment and drugs described in the texts did not in many cases reflect current Australian practice. For example, Rosen advises emergency physicians not to treat a rust ring and to refer the patient to an ophthalmologist.15 In Australia, an ophthalmologist, general emergency physician or ophthalmology registrar/emergency registrar could attend to rust rings. This means that in the absence of a comprehensive Australia-specific resource, practitioners who lack confidence and training in dealing with the ocular emergencies are reliant on resources that are of limited practical utility to them.
In addition to issues of assumed knowledge and differences in drugs/practice, another important consideration is the differences in terms of coverage and complexity between the various levels of texts reviewed. Although much of the information needed can be sourced in the specialist texts, this information is generally presented in language and terminology too complex for many non-specialist users. Likewise, although the general texts are more accessible in terms of language and terminology, they generally lack adequate detail.
A discussion of key resources would be incomplete without acknowledging that printed texts are not the only reference resources available. The internet provides users with access to a vast range of on-line resources through a number of search engines and by using various combinations of search words. These include ophthalmology websites such as http://www.rootatlas.com, http://emedicine.medscape.com/ophthalmology and http://www.eyecasualty.co.uk, which are also of UK or USA origin and are therefore subject to the same limitations as the print resources.
Online resources potentially offer users a more interactive, immediate and visual reference than the static text/photographs of the print resources. They also have the advantage that if specific topics are not covered in one particular website, this can be resolved by means of conducting additional searches until this specific information has been obtained. However, issues relating to the credibility and reliability of on-line resources are their main disadvantage. The print resources reviewed in the present paper have been written by well-regarded clinicians/academics. The credentials of web contributors are not always known. Fundamentally, unless the user knows where to look online, they might not find the references they require.
When an ocular emergency presents it is essential that the practitioner is able to recognize the severity of the condition and determine the urgency and appropriateness of treatment and/or referral. Our review has shown that no single resource exists that enables eye care providers to do so. For practitioners in a specialist eye department, the best-fit is a combination of the Wills Eye Manual7 and Kanski,8 the latter to provide photographs to complement the rich text contained in the former. For practitioners in general EDs, the Sydney Eye Manual10 offers the best-fit. The resource most often used by GPs16 needs to be accompanied by the Sydney Eye Manual10 for best-fit, recognizing that chronic conditions such as diabetic retinopathy still remain as a gap.
However, ‘best-fit’ is not the optimum solution. Our review of these 10 common resources has shown that no single resource covers all the crucial information needed. Furthermore, practitioners who deal with ocular emergencies have themselves reported a lack confidence and a need for training in dealing with such emergencies.3–5,7 The absence of a comprehensive Australia-specific resource means that these practitioners are reliant on whatever resources are available to offset deficits in confidence and training.
The present study reviews 10 resources for eye emergencies commonly used in Victorian EDs. Other resources might be used elsewhere in Australia or in New Zealand and this represents a possible limitation of the study.
Current rates of misdiagnosis in eye emergencies are unknown. What we do know is that documented misdiagnosis rates among referred patients have been as high as 64.1%.3 This review of the reference material available to eye care providers has shown that none of the print resources available for use in Australia covers all crucial clinical assessment and treatment issues in dealing with ocular emergencies. A single comprehensive reference (print and/or web-based) is clearly needed that will not only inform the management of ocular emergencies but also provide a structure for the development of curriculum and training.
CERA receives Operational Infrastructure Support from the Victorian Government.
PMO: substantial contributions to conception and design, and analysis and interpretation of data; as first author, drafting the article and undertaking revisions; final approval of the version to be published. CTC: substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published. RSD: substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; drafting the article and revising it critically for important intellectual content; final approval of the version to be published. JEK: substantial contributions to conception and design, and analysis and interpretation of data; revising it critically for important intellectual content; final approval of the version to be published.
- 2Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge: Harvard University Press, 1978., , .
- 4Confidence in the assessment of ophthalmological conditions amongst Victorian emergency physicians. Emerg. Med. Australas. 2006; 18 (Suppl 1): A1–17., .
- 6Victorian Ophthalmology Service Planning Framework [discussion paper]. Victoria, Australia: Metropolitan Health and Aged Care Services, Department of Human Services, 2004.
- 7The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th edn. Philadelphia: Lippincott Williams and Wilkins, 2008., , et al.
- 8Clinical Ophthalmology: A Systematic Approach, 6th edn. Oxford: Butterworth-Heinemann, 2007..
- 9Oxford Handbook of Ophthalmology. Oxford: Oxford University Press, 2006., .
- 10The Eye Emergency Manual. An Illustrated Guide, 2nd edn. Sydney: Department of Health, 2009. [Cited 11 Mar 2010.] Available from URL: http://www.health.nsw.gov.au/resources/gmct/ophthalmology/eye_manual_pdf.asp.
- 11TintinalliJE, GaborDK, StapczynskiJS, MaOJ, ClineDM, eds. Emergency Medicine: A Comprehensive Study Guide, 6th edn. New York: McGraw-Hill Professional, 2003.
- 12Emergency Ophthalmology. A Rapid Treatment Guide. Hong Kong: McGraw-Hill, 2002..
- 13DunnRJ, DilleySJ, BrookesJ et al., eds. The Emergency Medicine Manual, 4th edn. Tennyson: Venom Publishing, 2006.
- 14Textbook of Adult Emergency Medicine, 3rd edn. Edinburgh; New York: Churchill Livingstone Elsevier, 2009., , , , .
- 15MarxJA, HockbergerR, WallsR et al., eds. Rosen's Emergency Medicine Concepts and Clinical Practice, 6th edn. Philadelphia: Mosby, 2006.
- 16Murtagh's General Practice, 4th edn. North Ryde: McGraw-Hill, 2007..
- 17Australasian Triage Scale. [Cited 11 Mar 2010.] Available from URL: http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ATS.pdf