|I really enjoy practicing in the world of primary eye care. Refractions, non-invasive procedures, and providing eye wear and contact lenses to the public are a worthy calling for eye care professionals. But sometimes the medical and vision needs of patients become a little more complicated, and we must coordinate a higher level of care at a secondary or tertiary level with internists, MD’s, and ophthalmologists.
There are many levels of medical and eye care emergencies that we are called upon to resolve every day. There are some “emergencies” that are really minor problems to the eye care professional but may be considered a serious problem by the patient. Having a screw come out of a pair of eyeglasses is not a medical emergency, but when the patient is a 12 diopter myope and cannot see to drive, we must do everything possible to solve the problem quickly. A patient with a ripped contact lens who is leaving on vacation and does not have glasses or any other contact lenses may need help ASAP. But this is not a medical emergency. And, the most popular “emergency” is that emerging presbyope who has never worn glasses and “this morning”, cannot read the newspaper for the first time. The question that has to be evaluated is whether this really is presbyopia or could it be a retinal problem, cataract changes, or something worse. These presbyopic refractive changes must be differentiated from a myopic shift due to diabetes or a hyperopic shift due to a metabolic problem.
According to an August, 2012 Review of Optometry article, “Duke-Elder suggested that hyperglycemia causes a myopic shift, while a decrease in blood glucose levels leads to a hyperopic shift due to the osmotic force between the crystalline lens and aqueous humor that results from changes in molecular concentration. Some studies in which hyperglycemia was induced have shown a change in the thickness and/or curvature of the lens, altering its refractive index. Sito and Associates stated that the thickening of the lens correlates with the refractive shift towards hyperopia.”
Patients also often call because of simple sub-conjunctival hemorrhages that appear very severe to the patient because they are seeing blood in the eye. Usually patient reassurance is all that is necessary, but there should be a review of the patient’s blood pressure and blood pressure medications as well as telling the patient that these hemorrhages can appear from holding a sneeze, vigorous coughing or over exertion. Other less serious problems includes itchy eyes, redness, burning, and light sensitivity (photophobia). Some eye drops can cause pupil dilation. These drops may be adrenergic drops which can dilate a pupil. This pupil dilation needs to be differentiated from a retinal problem, an afferent pupillary defect, or a neurological problem and should be considered an emergency until proven otherwise.
There are other scenarios that entail listening to a patient on the phone when suddenly we realize that what is being described is not a minor problem, but is something that we must address immediately. Some of these more serious eye problems include a foreign body embedded in the cornea, conjunctiva, or elsewhere when not wearing safety glasses. I recently saw a case where a student was hit in the eye with a racquetball and was not wearing safety/sports glasses. There have been documented cases of vision loss by children playing soccer. Children “heading” a soccer ball can cause head injuries to a young, developing brain and can lead to vision problems. Patients who have undergone cataract surgery can suffer from retinal detachments after the surgery. There are other cases where people have a loss of their visual field in one or both eyes. This is an emergency situation where the underlying problems can be glaucoma, tumors, or aneurysms affecting the visual pathway. Large foreign objects stuck in the globe of the eye should never be touched or removed. Something of this serious a nature is probably best handled in the emergency room of a hospital.
When a patient calls the office of an eye care professional and is concerned about a sudden loss of vision, one of the worst possible causes is a retinal detachment. This sudden loss of vision is an emergency situation and timing is of the utmost importance. This is a case where a retinal specialist will have to intervene in order to do some form of retinal surgery to re-attach the retina. Sending a patient to a hospital emergency room will only delay a potentially positive outcome, unless a retinal specialist is on-call. This is a patient that needs to be seen on an emergency basis in a clinical eye care setting. ECPs should have the phone numbers of every medical specialist and ophthalmologist on their cell phones so they can make that important phone call for their patient.
What population group is at risk for retinal detachments? Those people who have had previous retinal tears, retinal detachments, or posterior vitreous detachments. High myopes are also at risk. Do not be lulled into thinking that retinal detachments cannot occur with lower amounts of myopia, because they do. The aging eye can be more at risk for retinal detachments, especially when you reach age 40 and beyond. Those people participating in contact sports who do not wear safety glasses are at high-risk for eye trauma and retinal detachments. The racquetball that is moving at 50 miles per hour can do major damage to the human eye. Boxers, baseball, basketball, and soccer players are also at risk. Diabetics who have retinal traction are at risk. Those families with a history of retinal detachments, previous eye injuries, and cataract surgery can place the eye at risk for retinal detachments as well.
What are some of the signs that can accompany a retinal tear or a retinal detachment? These signs may also be similar to a posterior vitreous detachment where the vitreous has detached from the retina. Flashes of light in the eye can be described by patients as “lightning bolts, starburst effects, or a flash cube from a camera.” This is the result of the retina being moved, pulled on, tugged, or torn. This has been referred to as a “neuro-electrical” phenomenon because the retina is a neurological tissue which receives electrical impulses of photons of light energy that has now been disrupted. The flashing lights are caused by the vitreous gel pulling on the retina. The changes to the vitreous allow the gel to push against the retina. Sometimes the flashes of light are accompanied by a shower of floaters. The floaters can be small pieces of cellular debris that have floated into the vitreous or can sometimes be one “blob” of dark material. Most floaters appear dark simply because they are casting a shadow on the retina. Some people describe their retinal changes like looking through a “cobweb”. The floaters are caused by the condensation in the vitreous gel and frequently are described by patients as spots, strands of hair, or little flies. There is no safe treatment to make the floater go away. The possibility of having a vitrectomy occurs only in extreme or emergency cases.
Other symptoms include “clouds” or “curtains” coming over one’s vision and peripheral vision loss is not unusual. If the patient experiences a shadow or curtain that affects any part of their vision, this can indicate that a retinal tear has progressed to a detached retina. There is no pain associated with retinal tears or detachments since the retina has no sensory nerves. Sometimes people try to “wipe away” what they think is a smudge on their eyeglasses that is not going away. A true tear will develop when fluid separates the retina from its underlying tissue. Once the retina has been torn, liquid from the vitreous can pass through or under the tear and accumulate “behind” the retina. As more of the vitreous collects behind the retina, the retinal detachment can progress and possibly detach a significant amount of the retina.
As eye care professionals, we love the challenge of being problem solvers whether it be putting a screw in a temple to repair a child’s glasses or making a phone call on behalf of a patient who has just suffered a serious injury. We are fortunate to be part of a profession that is diverse, challenging, and rewarding personally and professionally. But we must always be vigilant to “expect to see the unexpected”. And, we must be aware that the patient who believes that there is just a foreign body in their eye may have a far more serious condition to be treated.
This is Dr.Smith’s 16th article, published by Eye Care Professional Magazine.