On Call Ophthalmology

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Jainam Shah, Jason Zheng, Isabell Guzchenko, Katherine Han, Sachin Pathuri, Karl Golnik, MD, MEd, Bruce Becker, MD, Andrew Go Lee, MD, Anurag Shrivastava, MD

All contributors:

Jainam Shah, Jason Zheng, Sachin Pathuri, Isabell Guzchenko, Katherine Han, Karl Golnik, MD, MEd, Andrew Go Lee, MD, Anurag Shrivastava, MD, Bruce Becker, MD

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This article summarizes a practical framework for approaching overnight ophthalmology consultations in the emergency department, inpatient wards, intensive care units, and postoperative settings. It reviews preparation for call, urgency-based triage, focused bedside examination, and communication strategies for common ophthalmic presentations encountered overnight. Key vision-threatening and life-threatening conditions, including ocular trauma, acute angle-closure glaucoma, endophthalmitis, retinal detachment, orbital cellulitis, and neuro-ophthalmic emergencies, are highlighted with emphasis on timely recognition and escalation. The goal is to support efficient and clinically sound on-call decision-making while recognizing that local resources, institutional workflows, and clinical judgment should guide management.

Introduction

Overnight ophthalmology call requires rapid triage of vision-threatening and occasionally life-threatening conditions encountered in the emergency department, inpatient wards, intensive care units, and postoperative settings. The on-call ophthalmology resident or attending physician is frequently consulted for acute vision loss, ocular pain, trauma, postoperative complications, and neurologic or systemic conditions with ocular manifestations. '

Common overnight consults include open globe injuries, orbital fractures, acute angle-closure glaucoma, retinal detachment, posterior vitreous detachment, central retinal artery occlusion, endophthalmitis, orbital cellulitis, and corneal ulcers and perforations. The role of the on-call resident or attending physician is to identify conditions requiring immediate intervention, distinguish urgent from non-urgent pathology, perform a focused bedside examination, and communicate findings clearly with the primary team and supervising physician, with prompt recognition of high-risk findings being critical to prevent permanent vision loss. This article provides a structured framework for ophthalmology trainees covering overnight consults, including preparation, triage, focused examination, and communication.

Preparing for Call

Overnight ophthalmology consultations frequently occur in the emergency department, inpatient wards, intensive care units, and operating room settings, often without access to a full ophthalmic clinic. Prior to starting call, the resident should confirm availability of essential examination equipment, commonly used medications, and a clear escalation pathway to the senior resident, fellow, or attending physician.

Because many overnight evaluations must be performed at the bedside with limited resources, familiarity with handheld examination tools, safe dilation practices, and indications for urgent intervention is critical. Preparation should emphasize efficiency, portability, and readiness to evaluate vision-threatening conditions.  

Essential Equipment Checklist

The following items are commonly required for inpatient and emergency department ophthalmology evaluations. Availability may vary by institution; residents should verify the location of equipment before starting call.  

Item	Purpose	Notes
Penlight / transilluminator	Pupillary exam, anterior segment screening	Always carry
Near card / Rosenbaum card	Visual acuity testing	Document when appropriate
Pinhole occluder	Assess refractive component of decreased vision	Useful in bedside visual acuity exams
Slit lamp	Detailed anterior segment exam	Often available in ED
Direct ophthalmoscope	Basic fundus evaluation	Limited view but helpful when dilation is not possible
Indirect ophthalmoscope	Retinal evaluation, trauma, peripheral fundus exam	Preferred over direct for most on-call fundus evaluation
20D / 28D condensing lens	Used with indirect ophthalmoscope	Carry both if possible
Gonioscopy lens	Angle evaluation in suspected angle-closure	Requires slit lamp; may not be feasible in emergent settings like the ED
Dilating drops	Fundus examination	Do not dilate in suspected head injury or iris trauma, use caution in narrow angles
B-scan access	Posterior segment evaluation	Useful in trauma, vitreous hemorrhage, endophthalmitis
Fluorescein strips	Detect epithelial defects, Seidel test, corneal ulcers	Requires cobalt blue light
Cobalt blue light / wood lamp	Fluorescein examination	Often available in ED
Tonopen / handheld tonometer	Measure IOP	Avoid in open globe suspected
Tonopen covers / wipes	Infection control	Carry extras
Topical anesthetic	Improve comfort during exams	Avoid repeated outpatient use
Cotton-tip applicators	Lid eversion, foreign body removal	Useful in many exams
Eyelid speculum	Trauma or foreign body evaluation	Optional but helpful
Eye shield	Protect suspected open globe	Do not apply pressure; do not patch
pH paper	Chemical injury evaluation	Check before and after irrigation
Morgan lens	Ocular irrigation for chemical injury	Often available in ED
Muscle light	Motility assessment, cover-uncover test	Useful in trauma and diplopia evaluation

Commonly Used Medications

Note: Availability and institutional protocols may vary. Clinicians should be familiar with indications, contraindications, and appropriate escalation.

Medication	Typical Use	Contraindications
Artificial tears	Dry eye, irritation	No major contraindications
Proparacaine/tetracaine	Topical anesthesia	Avoid prescription for home use
Fluorescein	Corneal exam, Seidel test	Avoid in obvious open globe rupture
Pilocarpine	Acute angle-closure glaucoma	Avoid until IOP <40 mmHg; use caution in uveitic glaucoma
Tropicamide	Short-acting dilation	Use caution in narrow/occludable angles
Phenylephrine	Dilation	Avoid in severe hypertension, cardiac disease, infants
Cyclopentolate	Dilation; cycloplegia	Use caution in narrow / occludable angles
Atropine	Long cycloplegia	Use caution in narrow / occludable angles
Timolol	Lower IOP	Avoid in asthma, COPD, heart block, bradycardia
Brimonidine	Lower IOP	Contraindicated in infants (<2 yrs)
Dorzolamide	Lower IOP	Sulfa-related reactions possible
Acetazolamide	Systemic IOP reduction	Avoid in sulfa allergy, renal failure, liver disease
Mannitol	Severe IOP elevation	Avoid in heart failure, pulmonary edema; requires medical clearance
Fluoroquinolone drops	Corneal ulcers, abrasion, infection	Avoid contact lenses
Erythromycin ointment	Surface protection	Avoid contact lenses
Prednisolone acetate	inflammation	Avoid in active infection
Dexamethasone	Inflammation, inpatient setting	Avoid in active infection
Povidone-iodine	Pre-intravitreal injection, severe corneal ulcer protocols	Use diluted formulation; avoid in iodine allergy
Vancomycin / ceftazidime drops	Severe bacterial keratitis, endophthalmitis	Compounded; availability varies by institution

Situations Requiring Immediate Escalation

The on-call resident should notify the senior resident, fellow, or attending physician promptly in the following situations:

• Suspected open globe injury  

• Orbital compartment syndrome  

• Acute angle-closure glaucoma  

• Central retinal artery occlusion or acute vision loss of unclear cause  

• Suspected endophthalmitis  

• Orbital cellulitis with vision changes or afferent pupillary defect  

• Retinal detachment with decreased vision  

• Severe ocular trauma or penetrating injury  

• Postoperative patient with pain and decreased vision  

• Inability to complete examination due to patient condition  

• Any situation in which urgent surgical intervention may be required  

Early communication is recommended whenever uncertainty exists.

General Tips for Overnight Consults

• Always document visual acuity when possible

• Prepare basic portable equipment (vision card, fluorescein strips, tonopen wipes, etc.) in a readily accessible call kit

• Confirm the availability and location of essential equipment (slit lamp, B-scan, etc.)

• Consider globe rupture before performing tonometry or applying pressure

• Dilate when safe and not contraindicated  

• Provide clear instructions to patients in writing and their native language, without abbreviations.
• Ensure a qualified interpreter is used when needed.

• Escalate to the senior resident, fellow, or attending physician promptly when the diagnosis or management is uncertain.

Simplified Algorithm in Determining Urgency of Evaluation

While the more specific, pertinent questions to ask patients during the history gathering process would vary depending on the differential diagnoses that clinicians may already have in mind, there are general questions that may help guide the timing for ophthalmology evaluation. (Figure 1).

Figure 1: Flowchart depicting general questions to ask patients when determining the urgency for ophthalmology consultation (Courtesy of the American Academy of Ophthalmology). Flowchart available at: https://www.aao.org/Assets/491ffd27-3f66-4379-a754-689204385116/637986816034830000/03-ophthalmology-phone-triage-flow-chart-1-pdf?inline=1

Urgency-Based Diagnosis Table

The Emergency Severity Index (ESI) is a five-level emergency department triage system used in the United States that stratifies patients by both acuity and anticipated resource needs. ESI 1 represents the highest acuity (immediate, life- or organ-threatening), while ESI 5 represents non-urgent conditions.

The tables below categorize common emergent ophthalmic presentations by ESI level to guide on-call triage decision-making.

In clinical practice, not all listed conditions require emergency department evaluation or same-day management. Many may be appropriately managed in the outpatient setting or at the next available clinic visit. ESI 5 conditions generally do not require on-call assessment, and some ESI 4 conditions may also be deferred depending on clinical context. Furthermore, the acuity of a given condition may vary considerably between patients; for example, a patient with a small traumatic hyphema and normal intraocular pressure requires a different level of urgency than one with a total hyphema and elevated pressure, even though both fall under the same diagnosis.

This classification system is therefore intended as a practical framework to help on-call ophthalmologists prioritize and triage patient calls and presentations, rather than as a strict protocol mandating a specific time or setting of care. Clinical judgment should always supersede any triage classification system. As the Emergency Severity Index was developed for general emergency department triage and not specifically validated for ophthalmic conditions, its use here represents an adapted framework to aid clinical prioritization rather than a specialty-specific standard.

Anterior Segment

Condition	ESI Category
Chemical injury (alkali or acid)	ESI 1 — Immediate
Acute angle-closure glaucoma	ESI 2 — Emergency, within 10 minutes
Endophthalmitis (post-operative or endogenous)	ESI 2 — Emergency, within 10 minutes
Intraocular foreign body	ESI 2 — Emergency, within 10 minutes
Bacterial keratitis / corneal ulcer	ESI 3 — Urgent, within 30 minutes
Herpes simplex keratitis	ESI 3 — Urgent, within 30 minutes
Herpes zoster ophthalmicus	ESI 3 — Urgent, within 30 minutes
Scleritis	ESI 3 — Urgent, within 30 minutes
Anterior uveitis (acute)	ESI 3 — Urgent, within 30 minutes
Photokeratitis	ESI 4 — Semi-urgent, within 1 hour
Marginal keratitis	ESI 4 — Semi-urgent, within 1 hour
Episcleritis	ESI 4 — Semi-urgent, within 1 hour
Blepharitis	ESI 5 — Non-urgent, within 2 hours
Ectropion	ESI 5 — Non-urgent, within 2 hours
Entropion	ESI 5 — Non-urgent, within 2 hours
Trichiasis	ESI 5 — Non-urgent, within 2 hours
Pterygium	ESI 5 — Non-urgent, within 2 hours
Subconjunctival hemorrhage	ESI 5 — Non-urgent, within 2 hours
Viral conjunctivitis	ESI 5 — Non-urgent, within 2 hours
Allergic conjunctivitis	ESI 5 — Non-urgent, within 2 hours
Bacterial conjunctivitis	ESI 5 — Non-urgent, within 2 hours
Dry eyes	ESI 5 — Non-urgent, within 2 hours

Posterior Segment

Condition	ESI Category
Central retinal artery occlusion (CRAO)	ESI 1 — Immediate
Endophthalmitis (vitreous involvement)	ESI 1 — Immediate
Rhegmatogenous retinal detachment (macula-on)	ESI 2 — Emergency, within 10 minutes
Rhegmatogenous retinal detachment (macula-off)	ESI 3 — Urgent, within 30 minutes
Central retinal vein occlusion (CRVO)	ESI 3 — Urgent, within 30 minutes
Branch retinal artery occlusion (BRAO)	ESI 3 — Urgent, within 30 minutes
Vitreous hemorrhage	ESI 3 — Urgent, within 30 minutes
Posterior vitreous detachment (symptomatic, no detachment)	ESI 4 — Semi-urgent, within 1 hour
Wet age-related macular degeneration (new/acute)	ESI 4 — Semi-urgent, within 1 hour

Orbit and Adnexa

Condition	ESI Category
Orbital cellulitis (postseptal)	ESI 1 — Immediate
Cavernous sinus thrombosis	ESI 1 — Immediate
Preseptal (periorbital) cellulitis	ESI 2 — Emergency, within 10 minutes
Eyelid laceration involving canaliculus or lid margin	ESI 2 — Emergency, within 10 minutes
Eyelid laceration (simple, not involving margin)	ESI 3 — Urgent, within 30 minutes
Orbital floor fracture	ESI 4 — Semi-urgent, within 1 hour
Orbital medial wall fracture	ESI 4 — Semi-urgent, within 1 hour
Dacryocystitis (acute)	ESI 4 — Semi-urgent, within 1 hour
Chalazion / hordeolum	ESI 5 — Non-urgent, within 2 hours

Neuro-Ophthalmology

Condition	ESI Category	Notes
Cavernous sinus thrombosis	ESI 1 — Immediate	Risk of intracranial extension; urgent neuroimaging + anticoagulation
Pituitary apoplexy	ESI 1 — Immediate	Adrenal crisis risk; sudden vision loss + ophthalmoplegia + severe headache
CN III palsy (pupil-involving, new)	ESI 1 — Immediate	Posterior communicating artery aneurysm until proven otherwise; urgent CTA/MRA
Amaurosis fugax	ESI 2 — Emergency, within 10 minutes	TIA equivalent; urgent stroke workup
Arteritic ischemic optic neuropathy — GCA	ESI 2 — Emergency, within 10 minutes	Immediate IV methylprednisolone; fellow eye at risk within hours
Acute papilledema with threatened vision	ESI 2 — Emergency, within 10 minutes	Urgent LP ± neuroimaging to exclude mass
Orbital apex syndrome	ESI 2 — Emergency, within 10 minutes	CN II/III/IV/V1/VI involvement; urgent neuroimaging
Non-arteritic AION	ESI 3 — Urgent, within 30 minutes	Distinguish from arteritic; vascular risk factor modification
Optic neuritis (acute)	ESI 3 — Urgent, within 30 minutes	Rule out NMO (anti-AQP4/MOG); MRI brain and orbits
Acute homonymous hemianopia	ESI 3 — Urgent, within 30 minutes	Posterior cortical stroke or mass until proven otherwise
Internuclear ophthalmoplegia (INO), new onset	ESI 3 — Urgent, within 30 minutes	Brainstem lesion; bilateral INO = MS until proven otherwise
Acute diplopia (new CN IV or VI palsy)	ESI 3 — Urgent, within 30 minutes	MRI if atypical, painful, or young patient
Horner syndrome, new onset	ESI 3 — Urgent, within 30 minutes	Exclude carotid dissection; urgent CTA neck/head
Ocular myasthenia / myasthenic crisis	ESI 3 — Urgent, within 30 minutes	Risk of bulbar/respiratory involvement; CT chest for thymoma
Chronic papilledema / IIH without acute visual threat	ESI 4 — Semi-urgent, within 1 hour	Serial perimetry; acetazolamide; surgical options if progressive
Thyroid eye disease with compressive optic neuropathy	ESI 4 — Semi-urgent, within 1 hour	Orbital decompression if acuity or color vision deteriorating
Acquired nystagmus, new onset	ESI 4 — Semi-urgent, within 1 hour	Brainstem/cerebellar etiology until proven otherwise; MRI

Trauma

Condition	ESI Category
Ruptured globe / open globe injury	ESI 1 — Immediate
Sharp / penetrating ocular trauma	ESI 1 — Immediate
Traumatic hyphema with elevated IOP or total hyphema	ESI 2 — Emergency, within 10 minutes
Closed globe injury (significant blunt trauma)	ESI 3 — Urgent, within 30 minutes
Traumatic hyphema (small, IOP normal)	ESI 4 — Semi-urgent, within 1 hour
Corneal abrasion	ESI 4 — Semi-urgent, within 1 hour
Conjunctival laceration	ESI 4 — Semi-urgent, within 1 hour

Focused Bedside Exam Pearls

Visual Acuity

• Use a Snellen chart to measure visual acuity.  
• If unavailable, use a near card, newspaper, or magazine and record the smallest text the patient can read and the distance.  
• Patients should wear their usual distance glasses (if any) during testing.  
• Position the patient 20 feet from the chart and cover the eye that’s not being tested.  
• If vision is 20/40 or worse, repeat the test using a pinhole occluder (can be used over glasses).

In many cases of serious injury, the patient may be unable to read even the largest letter on an eye chart. If this is the case:

• Record the distance at which the patient can count fingers with the affected eye.
• If the patient cannot count fingers, determine the distance at which hand movement can be detected.  
• If the patient is unable to detect hand movement, use a penlight to determine whether he or she can perceive light.

Occasionally, clinicians will encounter a patient who is unwilling or unable to cooperate with standard visual acuity testing or who may be suspected of faking blindness. Because the typical visual acuity test will not work for such a patient, clinicians will need to be alert to other signs. Withdrawal or a change in facial expression in response to light or sudden movement indicates the presence of vision.

Lid Examination

• Foreign bodies may be lodged on the palpebral conjunctiva of the upper lid. Clinicians may evaluate this by having the patient look down while the clinician raises the upper lid.

• To evert the upper lid:
  • Ask patient to look down
  • Place the stick portion of a cotton swab approximately 10 mm above the upper lash margin.
  • Grasp the eyelashes with the other hand and gently pull straight out from the globe.
  • Pull the lashes up toward the forehead and flip the eyelid over, using the applicator stick as a fulcrum. Hold the eyelashes against the orbital rim with your thumb and withdraw the applicator. To return the lid to its normal position, the examiner releases the lid margin, and the patient is instructed to look up.

Fluorescein Staining

• Fluorescein is applied in the form of a sterile filter­-paper strip, which is moistened with a drop of sterile water or saline and then touched to the palpebral conjunctiva.  
• Clinicians should ask patients to blink their eyes a few times to spread the fluorescein over the cornea.  
• Areas of bright­-green staining under cobalt blue light denote absent or diseased epithelium.  
• Precautions to keep in mind when using fluorescein are:
  • Have the patient remove soft contact lenses prior to application to avoid discoloration of the lenses.
  • If the formulation includes an ester anesthetic, as is often the case, hypersensitivity to such agents is also a contraindication. Other contraindications include sensitivity to para-aminobenzoic acid.

Pupillary Testing

• In any case of trauma or decreased vision, check the eye for a relative afferent pupillary defect.
• Pupils should be inspected while the patient is looking at an object at a distance to avoid the pupillary constriction that occurs with a near target.  
• A bright light source should be held directly in front of one eye before moving rapidly across the bridge of the nose to the front of the other eye and then shifted back to the first eye.
• Poor pupillary dilation in dim light may indicate dysfunction of the sympathetic nervous system, and poor pupillary constriction to bright light may indicate parasympathetic dysfunction.

Direct Ophthalmoscopy

To perform direct ophthalmoscopy, follow these steps:

• Have the patient comfortably seated. Instruct the patient to look at a point on the wall straight ahead, trying not to move the eyes.
• Set the focusing wheel at about +8. Set the aperture wheel to select the large, round, white light.  
• Begin to look at the right eye about 1 foot from the patient. Use your right eye with the ophthalmoscope in your right hand. When you look straight down the patient's line of sight at the pupil, you should see the red reflex.  
• Place your free hand on the patient's forehead or shoulder to aid your proprioception and to keep yourself steady.  
• Slowly come close to the patient at an angle of about 15 degrees temporal to the patient's line of sight. Try to keep the pupil in view. Turn the focusing wheel to bring the patient's retina into focus.  
• When a retinal vessel comes into view, follow it as it widens to the optic disc, which lies nasal to the center of the retina.

Intraocular Pressure Measurement with Tono-Pen

• Confirm that tonometry is safe. Do not measure IOP if an open globe injury is suspected.  

• After allowing the Tono-Pen to calibrate, apply a sterile probe cover over the tip.

• Instill topical anesthetic to the patient’s eyes and ask the patient to blink to distribute the medication.  

• Ask patient to look straight ahead at a distant target. The examiner should keep the patient’s eyelids open without pressing on the globe. Stabilize your hand by resting your fingers on the patient’s forehead for stability.  

• Position the Tono-Pen perpendicular to the cornea and make multiple, rapid, and light taps to the central cornea.

• Always measure both eyes for comparison.  

• If measurements vary widely, repeat the test.  

• Ask patients to avoid squeezing eyelids, which falsely elevates IOP.  

Confrontation Field Testing

The examiner takes a position in front of the patient. The patient is asked to cover the left eye with the palm of the left hand; the examiner closes the right eye. Thus, the field of the examiner's left eye is used as a reference to assess the field of the patient's right eye. The patient is asked to fixate on the examiner's left eye and then count the fingers of the examiner in each of the four quadrants of the visual field. The examiner should repeat the process for the other eye.

Ocular Trauma

Open Globe Injury

Definition: Full-thickness wound of the eyewall (cornea/sclera). Includes penetrating, perforating injuries and intraocular foreign bodies.

Key Symptoms & Signs

Category	Findings
Symptoms	Pain, decreased vision
IOP	Normal or decreased
Pupil	Peaked pupil (pathognomonic), RAPD
Other	Hyphema, uveal prolapse, shallow anterior chamber

Management

Category	Action
Protection	Eye shield
Medications	Broad spectrum IV antibiotics (vancomycin, ceftriaxone, cefotaxime, ceftazidime, ciprofloxacin), antiemetics, pain control
Other	Tetanus prophylaxis, NPO, surgical removal of foreign object, surgical repair within 24 hours

Exam Considerations

• Avoid any pressure on the globe  

• Use CT (NOT MRI if metallic FB suspected)

• Perform Seidel test for aqueous leak

Triage Category

ESI 1 (immediate). Calculate the Ocular Trauma Score (OTS) to determine prognosis. Category 1 is associated with poor prognosis and lack of light perception, while Category 5 is associated with good prognosis and has the highest probability of visual acuity >20/200.

Orbital Compartment Syndrome

Definition: Compression and ischemia of the retina and optic nerve occur when intraorbital pressure exceeds ophthalmic artery pressure.

Key Symptoms & Signs

Category	Findings
Symptoms	Orbital pain, swelling, vision loss, diplopia, nausea, vomiting
External signs	Proptosis, periorbital edema, eyelid ecchymosis, resistance to retropulsion
Motility	Restricted extraocular movement, visual field defects
Conjunctiva	Chemosis, hemorrhage, injection
Pupil	Relative afferent pupillary defect (RAPD), internal ophthalmoplegia
IOP	Elevated; globe feels firm

Management

Category	Action
Emergency	Immediate lateral canthotomy/cantholysis or orbital decompression
Surgical	Orbitotomy ± needle decompression (if abscess or emphysema present)
Medications	Antiemetics, decongestants, stool softeners, pain control, antihypertensives
Other	Anticoagulation if thrombosis is suspected

Exam Considerations

• Identify cause of increased orbital volume (e.g., hemorrhage, emphysema, swelling).

• Imaging (CT with contrast or venography) obtained after decompression.

Triage Category

ESI 1 (immediate). Vision-threatening emergency requiring treatment ideally within 90 minutes.

Chemical Injury

Definition: Ocular chemical injury can be due to acidic or alkaline substances.

Key Symptoms & Signs

Category	Findings
External signs	Particulate matter, eyelid malposition
Cornea	Epithelial defects, ground-glass appearance (acid), liquefactive necrosis (alkali)
Conjunctiva	Limbal ischemia, scarring, symblepharon
IOP	Elevated due to trabecular meshwork damage
Other	Corneal opacity, forniceal shortening, entropion/ectropion

Management

Category	Action
Immediate	Copious irrigation ≥15 minutes until pH 7.0–7.2
Technique	Irrigate nasal → lateral; evert eyelids
Medications	Based on severity (antibiotics, steroids, cycloplegics, vitamin C)
Other	Avoid eye patching

Exam Considerations

• Perform exam only after pH stabilization

• Use fluorescein to assess epithelial damage

• Grade severity using Hughes classification.

Triage Category

ESI 1 (immediate). Do not delay irrigation for history or exam..

Orbital Fractures

Definition: Fractured or broken bones surrounding the orbit, which include orbital rim fractures, blowout fractures, and orbital floor fractures.

Key Symptoms & Signs

Category	Findings
Symptoms	Diplopia, blurry vision or vision loss, pain, swelling, numbness
External signs	Bruising, eyelid swelling, enophthalmos, trismus
Motility	Restricted movement (especially upward gaze)
Neuro	Possible intracranial injury
Eye	Hyphema, corneal abrasion, RAPD
Other	Oculocardiac reflex (bradycardia, syncope)

Management

Category	Action
IOP >40 mmHg	Immediate canthotomy/cantholysis
Mild	Ice packs, observation
Severe	Surgical repair (implant fixation, decompression)
Other	Avoid nose blowing

Exam Considerations

• Perform full neurological assessment.

• Obtain CT scan or orbital X-rays.

• Evaluate for muscle or nerve entrapment.

Triage Category

ESI 2–4 (severity-dependent). Escalate to ESI 1 if optic nerve compression, muscle entrapment, or elevated IOP is present.

Eyelid Lacerations

Definition: Blunt or lacerating trauma to the eyelids. These injuries can be simple or complex.

Key Symptoms and Signs

Category	Findings
Symptoms	Pain, tearing, bleeding, swelling, numbness
External	Eyelid margin involvement, fat prolapse, tissue loss
Vision	Assess visual acuity prior to intervention
Pupils	Evaluate pupillary response and red reflex

Management

Category	Action
Initial	Keep wound moist with topical erythromycin and avoid premature tissue removal (including necrotic tissue)
Surgical	Urgent repair by an oculoplastic surgeon. Consult with ENT surgeons for sinus involvement and neurosurgeons for intracranial involvement.
Other	Ensure sutures do not contact the cornea

Exam Considerations

• Assess for canalicular/lacrimal system involvement.

• Obtain CT imaging if indicated.

• Evaluate for associated intracranial injury.

Triage Category

ESI 2 to ESI 3 depending on complexity. Urgency escalates with canalicular involvement, associated orbital injury, or intracranial extension.

High-Yield Non-Traumatic Emergencies  

Acute Angle-Closure Glaucoma

Definition: Increased intraocular pressure due to mechanical occlusion of the trabecular meshwork that impairs aqueous outflow.

Key Symptoms and Signs

Category	Findings
Symptoms	Acute vision loss, blurred vision, headache, nausea/vomiting
Vision	Markedly reduced visual acuity
IOP	Elevated (typically 40–80 mmHg); globe feels firm
Pupil	Mid-dilated, fixed, non-reactive pupil
Cornea	Hazy/edematous
Other	Conjunctival injection, shallow anterior chamber

Management

Category	Action
Initial	Topical timolol, topical apraclonidine, IV/PO acetazolamide
Additional	Pilocarpine (once IOP <40 mmHg)
Refractory	IV mannitol
Supportive	Antiemetics to reduce Valsalva
Definitive	Laser peripheral iridotomy (LPI)

Exam Considerations

• A gonioscopy confirms diagnosis (≥180° closure).

• Evaluate the unaffected eye as there is a higher risk for occurrence from baseline in the opposite eye.

• Avoid misdiagnosis as neurologic or abdominal pathology, which is how it may initially present.

Triage Category

ESI 1 (immediate). Irreversible optic nerve damage can occur within hours and requires immediate IOP-lowering therapy and urgent ophthalmology consultation.

Central Retinal Artery Occlusion

Definition: An acute occlusion of the central retinal artery (also known as an ocular stroke), usually from thromboembolism, resulting in retinal ischemia and sudden vision loss.

Key Symptoms and Signs

Category	Findings
Symptoms	Sudden, painless, severe monocular vision loss
Vision	Counting fingers, hand motion, or light perception
Pupil	RAPD
Fundus	Retinal whitening, cherry-red spot, attenuated arterioles
Visual Field	Near-complete loss (may spare small area)

Management

Category	Action
Immediate	Activate stroke protocol
<4.5 hrs	Consider IV tPA (in consult with the stroke team)
>4.5 hrs	Antiplatelet therapy, stroke workup
Arteritic	Immediate IV corticosteroids (suspected giant cell arteritis (GCA), which can lead to vision loss)
Other	Avoid delaying care with ineffective therapies

Exam Considerations

• Optical coherence tomography (OCT) confirms retinal ischemia.

• Labs: ESR/CRP (to rule out GCA)

• Obtain a full stroke workup (ECG, carotid imaging, echo).

Triage Category

ESI 1 (immediate). Retinal damage begins within 90-100 minutes. Treat as stroke equivalent ("eye stroke").

Giant Cell Arteritis (GCA)

Definition: A granulomatous vasculitis of medium and large vessels, most commonly affecting the branches of the external carotid artery. It is the most common cause of arteritic ischemic optic neuropathy (AION) and represents one of the most vision-threatening emergencies in ophthalmology, with the fellow eye at significant risk within hours to days if untreated.

Key Symptoms and Signs

Category	Findings
Symptoms	Sudden vision loss, scalp tenderness, jaw claudication, temporal headache, fatigue, fever, weight loss
Vision	Sudden, severe, often painless monocular vision loss
Pupil	RAPD
Fundus	Pale, swollen optic disc (chalky white edema characteristic of arteritic AION)
Other	Tender, nodular, or pulseless temporal artery on palpation

Management

Category	Action
Immediate	High-dose IV methylprednisolone 1g daily for 3 days
Subsequent	Transition to oral prednisone 1mg/kg/day
Labs	ESR, CRP, CBC, platelet count (thrombocytosis supportive of diagnosis)
Definitive	Temporal artery biopsy within 2 weeks of starting steroids
Other	Do not delay steroids pending biopsy; aspirin 81mg if no contraindication

Exam Considerations

• Biopsy should not delay initiation of corticosteroids
• Contralateral eye is at risk; fellow eye involvement can occur within hours to days without treatment
• ESR and CRP are sensitive but not specific; a normal ESR does not exclude GCA
• Consider rheumatology consultation for long-term management

Triage Category

ESI 1 (immediate). Do not delay corticosteroid therapy pending confirmatory testing. The fellow eye is at imminent risk and vision loss is typically irreversible once it occurs.

Endophthalmitis

Definition: A purulent intraocular infection involving the vitreous and aqueous humor, most commonly following surgery, trauma, or hematogenous spread. The types are defined by endogenous and exogenous routes of infection entry.

Key Symptoms and Signs

Category	Findings
Symptoms	Eye pain, redness, decreased vision
Vision	Rapidly worsening (can be hand motion or light motion)
External signs	Lid swelling
Anterior	Hypopyon, anterior chamber inflammation
Posterior	Vitritis, vitreous haze
Other	Absent or diminished red reflex

Management

Category	Action
Initial	Intravitreal antibiotics (vancomycin + ceftazidime)
Mild (+ hand motion)	Tap and inject
Severe (light perception or worse)	Pars plana vitrectomy
Endogenous	Add systemic antibiotics ± antifungals
Fungal	Add intravitreal antifungal

Exam Considerations

• Obtain a B-scan ultrasound if there is poor visualization.

• Obtain vitreous/aqueous cultures to control for infection.

• Monitor for high suspicion post-surgery or trauma.

Triage Category

ESI 1 (immediate). Vision outcomes depend on time to treatment and requires immediate ophthalmology involvement.

Orbital Cellulitis

Definition: Infection posterior to the orbital septum involving orbital tissues, most commonly from sinus spread. This diagnosis must be distinguished from preseptal cellulitis.

Key Symptoms and Signs

Category	Findings
Vision	Decreased
Pain	Pain with eye movement
Motility	Restricted (ophthalmoplegia)
External	Proptosis, eyelid edema
Pupil	RAPD (optic nerve involvement)
Other	Fever, leukocytosis, chemosis

Management

Category	Action
Preseptal	Oral antibiotics with MRSA coverage if indicated (trimethoprim-sulfamethoxazole or clindamycin)
Orbital	Admit patient for intervention; IV vancomycin + broad-spectrum coverage
Surgical	Drain abscess or if no improvement in 24-48 hrs
Emergency	Canthotomy if orbital compartment syndrome develops

Exam Considerations

• Obtain CT orbit/sinuses with contrast.

• Obtain an ENT consult if there is a sinus source.

• Monitor for intracranial complications and consult with neurosurgery if symptoms worsen.

Triage Category

ESI 4 (if preseptal) to ESI 1 (if orbital). Urgency escalates in the setting of optic neuropathy, orbital compartment syndrome, or abscess formation.

Retinal Detachment

Definition: Separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). The most common type is rhegmatogenous retinal detachment (RRD), which occurs due to a full-thickness retinal break allowing liquefied vitreous to accumulate in the subretinal space. Other types include tractional and exudative retinal detachments.

Key Symptoms and Signs

Category	Findings
Symptoms	Sudden onset floaters, flashes of light (photopsia), peripheral visual field loss ("curtain" or "shadow"), painless
Vision	Variable; reduced acuity if macula involved
Pupil	RAPD if extensive detachment
Fundus	Elevated, billowing retina; retinal break or tear; tobacco dust (Shafer sign) in vitreous
Other	Reduced IOP compared to fellow eye

Management

Category	Action
Macula-on	Urgent surgical repair; same-day or next morning to preserve central vision
Macula-off (recent, <1 week)	Urgent surgical repair; timing less critical but prompt intervention improves outcomes
Macula-off (chronic, >1 week)	Semi-urgent; schedule elective repair
Surgical options	Pneumatic retinopexy, scleral buckle, pars plana vitrectomy (PPV)
NPO	If surgery anticipated

Exam Considerations

• Dilated fundus exam with indirect ophthalmoscopy is essential
• Scleral depression to identify peripheral breaks
• B-scan ultrasound if media opacity prevents fundus visualization
• Examine the fellow eye for lattice degeneration or peripheral breaks

Triage Category

ESI 2 (macula-on) to ESI 3-4 (macula-off, depending on chronicity). Macula-on detachments should be treated as emergencies to prevent macular involvement and preserve central vision. Macula-off detachments require prompt but not necessarily immediate intervention, with urgency guided by duration of macular involvement.

Documentation and Communication

General Useful Information to Gather for Ophthalmology Consultation

Other services consulting ophthalmology may use the general guide below when presenting information to ophthalmology residents or attendings for consultation:

• Date and time that the patient presented

• Requesting service and reason for consultation

• Patient’s chief complaint

• History of presenting illness
  • Onset
  • Duration and progression
  • Triggers (trauma/chemical exposure)
  • Laterality (OS/OD/OU)
  • Pain (severity, with eye movement?)
  • Associative symptoms (erythema, floaters, diplopia, discharge, etc.)
  • Prior episodes if any, types of treatment received, and outcomes

• Past ocular history
  • Diagnoses
  • Surgeries
  • History of trauma
  • Use of glasses or contact lenses

• Other relevant past medical history
  • Hypertension
  • Diabetes
  • Thyroid eye disease
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Other systemic or autoimmune conditions

• Medications and allergies

Sample Ophthalmology Consult Note Template

Below is an example of an ophthalmology consult note template commonly used in common EMR platforms (e.g. Epic).

CC/HPI

[Patient Name] is a [age]-year-old [male/female] with a history of [PMH], presenting with [chief complaint]. Ophthalmology was consulted for further evaluation.

The patient reports [symptoms].

The patient denies ocular pain, redness, foreign body sensation, itching, burning, tearing, discharge, flashes, floaters, diplopia, or photophobia.

No prior ocular history. No history of ocular surgery. Not using ocular medications. No known family history of ocular disease.

PMH:

PSH:

FamHx:

SocHx:

Current Meds & Allergies

Relevant medications patients is taking for both systemic conditions and/or ophthalmic condition. Document any known allergies.

Vital Signs

	OD	OS
Visual Acuity (near)	20/ [ ]	20/ [ ]
Pupils	RR, no RAPD	RR, no RAPD
IOP (Tonopen)	[ ] mmHg	[ ] mmHg
Visual Fields (confrontation)	Full	Full
Color Vision (Ishihara)	11/11	11/11
EOM	Full, Ortho	Full, Ortho

	OD	OS
External	WNL	WNL
Lids/Lashes	WNL	WNL
Conj/Sclera	White and quiet	White and quiet
Cornea	Clear	Clear
Anterior Chamber	Deep and Quiet	Deep and Quiet
Iris	WNL	WNL
Lens	Clear	Clear

Dilated Fundus Exam: Patient dilated with 2.5% phenylephrine and 1% tropicamide

	OD	OS
Vitreous	Clear	Clear
Disc	Sharp and pink	Sharp and pink
C/D ratio	0. [ ]	0. [ ]
Macula	Flat, + FLR	Flat, + FLR
Vessels	WNL	WNL
Periphery	WNL, no tears, holes or detachments	WNL, no tears, holes or detachments

Imaging

	OD	OS
B-scan ultrasound	Retina flat, no vitritis	Retina flat, no vitritis

Assessment/Plan

[Patient Name] is a [age]-year-old [male/female] with [summary diagnosis].

# [Problem]

• [Assessment sentence — what you think it is]
• [Key supporting findings]
• [Plan: meds / imaging / follow-up]

Regardless of the consult template used, below are detailed points to include and consider in every new patient consult performed:

• Subjective

1. Chief Complaint: [briefly describe the main reason for the visit]  
2. History of Present Illness: [details about the onset, duration, severity, and character of the visual complaint]
3. Past Ocular History: [history of previous eye diseases, surgeries, treatments, and outcomes]
4. Medical History: [relevant systemic conditions affecting ocular health]
5. Medication History: [current ocular and systemic medications]
6. Allergies: [medication and substance allergies]
7. Family Ocular History: [family history of eye diseases]
8. Social History: [tobacco use, alcohol use, occupational hazards]

• Objective

1. Extraocular Movements: [full/restricted, presence/absence of pain with movement]
2. Visual Acuity: [findings for visual acuity without correction and with correction, for each eye (OD, OS)]
3. Pupils: [size, symmetry/asymmetry, presence/absence of RAPD]
4. External Exam: [findings from lids and lashes such as proptosis and ptosis]
5. Intraocular Pressure: [measurement method and values for each eye (OD, OS)]
6. Anterior Segment: [findings from slit-lamp examination]
7. Posterior Segment: [findings from dilated fundus examination]
8. Additional Tests: [results of additional tests such as OCT and fluorescein angiography]

• Assessment

1. Diagnosis [ICD-10 code]

• Plan

1. Treatments: [planned treatments such as medications, laser therapy, or surgical interventions]
2. Workup: [further labs and imaging]
3. Follow-Up: [specified interval until next visit]
4. Patient Education: [information provided about diagnosis, treatment, and prognosis]
5. Referrals: [referrals to other specialists if any]