Which conditions should prompt emergent ophthalmologic consultation?
Which conditions require prompt imaging and/or consultation with neurologists or neurosurgeons?
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Ophthalmologic concerns in the hospitalized patient fall into two broad categories: signs and symptoms of the systemic condition for which the patient has been admitted, and unrelated but potentially urgent disorders of the eye that may threaten vision. While some of the conditions discussed in this chapter may relate to the former issue, our approach will be to describe common ophthalmologic disorders for which inpatient consultation is often considered, and to provide information on appropriate triage and workup prior to obtaining the consultant's opinion. In many cases, outpatient evaluation after the acute illness has passed may be more useful, since the patient's cooperation with subjective testing methods is much more reliable. Symptoms that may prompt urgent evaluation include red eyes (with or without pain), double vision, and subjective loss of vision. There are a number of bedside examination techniques that do not require specialized equipment but can yield important information to narrow the differential diagnosis and help determine the urgency of further testing.
The consulting physician should perform a focused but detailed eye history and physical examination prior to consulting an ophthalmologist. Time of onset, monocular or binocular nature, duration, and associated neurologic symptoms are especially important. Past medical and ocular history are relevant, as are recent interventions during the current hospitalization that might contribute to the visual complaints. The examination should ideally include best corrected visual acuity (with glasses) measured for each eye, either with a near reading card or distance chart. It should be noted whether the pupils are equal in size and reactive to illumination. Abnormal extraocular movements may be seen with new binocular double vision. Peripheral vision testing with a small red object (pinhead, marker cap) can detect up to 75% of clinically relevant deficits. Finally, a hand-light examination should be done at the bedside to look for eyelid swelling or redness, conjunctival hyperemia and discharge, corneal clarity or haze, and gross iris and anterior segment abnormalities. If a direct ophthalmoscope is available, examination of the fundus should be attempted. This is best done in dim lighting so that the pupil is somewhat large. If a normal appearance of the optic nerves, retinal vessels, and maculae can be confirmed, this can be very helpful. This requires some level of practice and proficiency, but is within the scope of physical examination techniques of every physician.
Ophthalmologic consultation is required for any condition that may cause severe and permanent vision loss, including
- Corneal ulcers
- Acute angle glaucoma
- Sudden visual loss
- Orbital mass, including orbital abscess
- Stevens Johnson Syndrome with mucosal involvement.