The following pathway will continue post-pandemic
Direct dial from HRI 152539, From CRH 2539.
ED to Opthalmology COVID-19 Referral Pathway v2Category: Ophthalmology
Giant Cell Arteritis – GCA
GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA is far from a benign condition that can be passed back to the GP’s, it can lead to some significant problems
- Sudden irreversible visual loss
- Development of thoracic aortic aneurysm
PEARS
COVID-19 (Escalation-Ophthalmology Referral)
Any patient presenting to ED with ONLY Ophthalmic symptoms should be referred directly by the ED triage team to Ophthalmology:
Referral
- 08:30 – 17:30 Mon-Fri, and 09:00 – 12:00 Sat all referrals are to be made directly to dedicated phone
- Out is these times refers to Ophthalmology on-call
Minimum dataset:
-
- Referrer name + grade + location.
- Patient details – 3 points of ID (name + D.O.B. + NHS / hospital number).
- Best contact number for patient.
- COVID-19 status of patient.
- Asymptomatic, COVID-19 NOT suspected.
- Symptomatic, COVID-19 SUSPECTED.
- Symptomatic, COVID-19 CONFIRMED.
- Ophthalmic symptoms / signs on presentation.
Any patient presenting to ED with Ophthalmic symptoms/signs IN ADDITION TO other systemic issues should continue to be assessed and managed by ED as normal:
- Refer as above once deemed stable
- If admitted under another team (e.g medics) – ensure admitting team area aware that the referral is still to be made (Document clearly in notes and verbally hand over)
Retrobulbar haemorrhage
What is retrobulbar haemorrhage?
- Rapidly progressing haemorrhage into the retrobulbar space which is rare but potentially sight threatening.
- Retrobulbar haemorrhage causes a rapid rise in intraorbital volume and pressure.
- If not treated it can quickly lead to retinal ischaemia and infarction resulting in permanent visual impairment or complete visual loss.
Lateral Canthotomy
Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well
Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.
- Blood collects in the retrobulbar space
- Pushing the eye forward to accommodate the extra volume.
- The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.
Recognition
- Severe pain
- Red/Congested conjunctiva
- Exophthalmos with proptosis – eye pushed forward
- Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
- Visual flashes
- Loss of vision – initially colour vision (esp. red), progressing to local visual loss.
However, this may only be recognised on CT if there is significant facial injury and altered conscious level.
Treatment
Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.
Kit needed
- Lidocaine with adrenaline (needle & syringe)
- Clamp – ideally curved to crush the tissues
- Forceps
- Scissors
Resources
- Royal College of Ophthalmologists – Traumatic Orbital Emergencies
- Making a training model – Great article covering it HERE
- Tips not in the paper
- Creme Fraiche Pot – works (use 53mm paper tube to hold eye in place)
- Cut square hole 34x34mm
- Rubber band cut 40mm slit
- Reinforce the Eyelid corners with foam so the rubber band doesn’t stick (i.e. small square facing down
- When applying the foam eye lids ensure cants at the corners of the square
- Tips not in the paper
